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LIBRARY 

Walter E. Fernald 
State School 




Waverley, Massachusetts 



No. 




THE FIRST SIGNS OF INSANITY 



ANOMALIES OF THE ENGLISH LAW. 

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THE FIRST SIGNS OF 

INSANITY 

THEIR PREVENTION AND TREATMENT 

setts c 

BY 

BERNARD HOLLANDER, M.D. 

author of 

"the mental functions of the brain," "scientific phrenology," 

"hypnotism and suggestion," "the mental symptoms 

of brain disease," etc. 



LONDON 

STANLEY PAUL & CO 

31 ESSEX STREET, STRAND, W.C. 



PRINTED BY 
HAZELL, WATSON AND VINEY, LD. 
LONDON AND AYLESBURY. 



PREFACE 



There are many excellent text-books on Insanity, but 
nearly all deal with the subject from the standpoint of 
the Asylum Superintendent, whose experience is chiefly 
with the advanced stages of the disease. This book has 
been written from a different point of view. It is the 
work of a physician who has made a special study of 
the signs and symptoms of the early phases of mental 
disorder, and their successful treatment. He contends 
that, although our asylums are model institutions, 
admirably conducted, and absolutely indispensable, yet, 
since nowadays we diagnose very mild and harmless 
cases, we require in addition to such institutions other 
facilities for treatment. In his opinion it is essential 
to the recovery of the patient that his treatment should 
not be delayed until he can be " certified " for an asylum, 
but should commence as soon as symptoms of mental 
disorder manifest themselves, and that such treatment 
must be individual, either in private care, or in an observa- 
tion ward, or reception hospital. 

The author's aim is to point out to all interested in 
the subject, whether medical practitioner, psychologist, 
sociologist, or general student, the fine distinctions 
between the normal and abnormal mind, rational and 
unsound thought, healthy and perverted feelings, and 
responsible and irresponsible conduct. For this purpose 
he has endeavoured to give — in Part I of the book — a 
description of the various mental powers which make 
up our mind and character, and showing their activity ; 
first of all under normal circumstances and secondly 
under the influence of disease. This description of 
normal and abnormal mental activity is so arranged as to 



6 PREFACE 

make the early manifestations of insanity easy to diagnose 
and therefore more accessible to treatment. 

In Part II the author discusses the various causes 
of Insanity, including hereditary disposition, mental and 
moral causes, inebriety, toxines, etc. The problem of 
heredity, the drink problem, and the other questions 
involved in the causation of mental derangement are 
discussed from a common-sense point of view and from 
the author's own experience. 

The author deals next — in Part III — with the pre- 
vention and treatment of mental infirmity and disease. 
He describes : 

i. The precautionary methods that should be adopted 
by individuals in whose family there is a neurotic 
taint i and the methods of upbringing, of 
education, and of conduct in life that should be 
avoided where a man is handicapped by a bad 
heredity to unsoundness of mind or nervous 
disease. 

2. The methods to be adopted by municipalities, whose 

business it is to make provision for the ever- 
increasing mass of insane and feeble-minded. 

3. He discusses the value of the various measures 

which have been proposed for the improvement 
of the race, such as : restriction of marriage, 
sterilisation of the unfit, and the segregation 
of the incurable insane and feeble-minded in 
industrial colonies. 
In Part IV the author gives a detailed description 
of the signs and symptoms of the various forms of in- 
sanity and weak-mindedness, which should prove of 
value to the medical practitioner and general student. 

Lawyers will be interested in those forms of insanity 
in which there is a loss of control over the passions and 
conduct while the reasoning power as well as the judgment 
of what is right and wrong are preserved, rendering it 
difficult to distinguish between folly and iniquity, in- 
sanity and crime. The classification of the criminal 
tendencies of the insane (Chapter XXVII) should prove of 
practical value to them and to medical experts in determin- 
ing whether a prisoner is insane and what is the particular 
variety of mental disorder from which he is suffering. 



PREFACE 7 

Since the subject is one likely to appeal not merely to 
medical men, but to a wide circle of readers, the author 
has endeavoured to express himself in popular language, 
and has avoided so far as possible such technical matters 
as are still subject to dispute amongst lunacy experts, 
his chief aim being to create a book of genuine practical 
utility. 

As the work is one dealing with perhaps the most 
far-reaching and most dreaded of maladies to which 
mankind is heir, and the problem of providing for the 
weak-minded, insane, and otherwise degenerate is one 
which must seriously affect communities and the State, 
the author ventures to hope that the subject will receive 
due consideration by those who are in a position to 
influence public opinion. In view also of the evidence 
given before the Royal Commission on the Care and 
Control of the Feeble-minded, and the attempts which 
are to be made to obtain greater facilities for the treat- 
ment of incipient insanity, the time should be opportune 
for a book describing " The First Symptoms of Insanity 
— their Prevention and Treatment/ ' 



57, Wimpole Street, London, W 
April, 1912. 



CONTENTS 



PAGE 

INTRODUCTION 15 



PART I 

THE FIRST SIGNS OF INSANITY 

MIND AND CHARACTER, NORMAL AND ABNORMAL 

CHAPTER I 

WHEN IS A PERSON INSANE ? . . 3 1 

CHAPTER II 

DISORDERS OF THE ANIMAL PASSIONS . 41 

CHAPTER III 

DISORDERS OF THE SOCIAL AFFECTIONS . 54 

CHAPTER IV 

DISORDERS OF THE INTELLECT: 
PERCEPTION, MEMORY, REASON. 
HALLUCINATIONS, ILLUSIONS, DELUSIONS . 62 

CHAPTER V 

DISORDERS OF THE HIGHER HUMAN CAPACITIES. 

GENIUS, ECCENTRICITY, AND INSANITY . 79 

9 



io CONTENTS 

PART II 
THE CAUSES OF INSANITY 



CHAPTER VI 

PAGE 

HEREDITARY DISPOSITION TO INSANITY . 93 

CHAPTER VII 

THE INCREASE IN INSANITY. 
THE EFFECT OF ADVANCING CIVILISATION ON 
THE MIND OF MAN. 
MENTAL AND MORAL CAUSES OF INSANITY . 107 

CHAPTER VIII 

INEBRIETY AS A CAUSE OF INSANITY . 123 

CHAPTER IX 

TOXIC AND OTHER CAUSES OF INSANITY . 131 



PART III 

THE PREVENTION AND TREATMENT 
OF INSANITY 



CHAPTER X 

THE MENTAL FUNCTIONS OF THE BRAIN . 143 

CHAPTER XI 

MENTAL DISCIPLINE AS A PREVENTION OF INSANITY 152 



CONTENTS II 

CHAPTER XII 

PAGE 

THE PRIVATE TREATMENT OF INSANE. 
PSYCHO-THERAPEUTIC AND HYGIENIC MEASURES l6o 

CHAPTER XIII 

SURGICAL TREATMENT OF SOME FORMS OF INSANITY 176 

CHAPTER XIV 

THE TREATMENT OF THE INSANE 
IN PRIVATE CARE, RECEPTION HOUSES, 

AND OBSERVATION CLINICS . . 185 

CHAPTER XV 

THE VALUE OF PROPOSED PREVENTIVE MEASURES I 
RESTRICTION OF MARRIAGE OF INSANE, 
STERILISATION OF THE DEGENERATE, 
AND THE SEGREGATION OF THE FEEBLE-MINDED 199 

PART IV 

THE VARIETIES OF INSANITY AND 
FEEBLE-MINDEDNESS 

CHAPTER XVI 

mental symptoms accompanying brain fatigue 

(neurasthenia): 
indecision, obsessions, and morbid fears 213 

CHAPTER XVII 

the mental symptoms of hysteria . 220 



12 CONTENTS 

CHAPTER XVIII 

PAGE 

STATES OF MENTAL EXALTATION AND EXCITEMENT. 

MANIA . . . .,-; 225 



CHAPTER XIX 

STATES OF MENTAL DEPRESSION. 

MELANCHOLIA . . . 231 



CHAPTER XX 

PERIODIC ATTACKS OF INSANITY . 245 

CHAPTER XXI 

PROGRESSIVE INSANITY WITH SYSTEMATISED DE- 
LUSIONS (PARANOIA) . . .250 

CHAPTER XXII 

STATES OF MENTAL ENFEEBLEMENT I 
GENERAL PARALYSIS, DEMENTIA PRECOX, 
PRIMARY DEMENTIA, AND SENILE INSANITY 260 

CHAPTER XXIII 

MENTAL DISORDERS DUE TO INTOXICATION : 
ALCOHOL, OPIUM, AND COCAINE POISONING . 273 

CHAPTER XXIV 

MENTAL DISORDERS PECULIAR TO WOMEN. 285 



CONTENTS 13 

CHAPTER XXV 

PAGE 

MENTAL AFFECTIONS OF CHILDHOOD: 
NIGHT TERRORS, CHOREIC AND EPILEPTIC 

INSANITY . . . 290 

CHAPTER XXVI 

STATES OF ARRESTED MENTAL DEVELOPMENT: 
IDIOCY, IMBECILITY, FEEBLE-MINDEDNESS, AND 

MORAL WEAK-MINDEDNESS . . 297 

CHAPTER XXVII 

INSANITY AND THE LAW : 
THE CRIMINAL INSANE AND THE INSANE CRIMINALS 311 

INDEX ... 337 



INTRODUCTION 

It is difficult to get rid of antiquated notions on the 
subject of lunatics. The popular impression would 
seem to be that the insane are generally raving and 
desperate people, whose actions resemble those of beasts 
and whose language is that of Billingsgate ; that conse- 
quently they ought to be deprived of liberty and kept 
in specially built places of safety where they are pro- 
tected from doing harm either to themselves or to others. 
This was the prevalent idea when asylums were first 
established, at a time when only the worst cases were 
admitted as insane. Even a century ago insane patients 
were still treated more like furious beasts than human 
beings. They were shown to the public on certain days 
of the week, like lions in a menagerie, at the charge of 
twopence. It was the custom for the ruffians of the 
town to jeer and mimic the demented inmates in order 
to excite them to rage. Refractory patients were 
heavily chained ; sometimes even those who were not 
violent were fastened like dogs to the wall. In another 
part of the house women were to be found locked in 
cells, naked and chained, lying on straw, with only one 
blanket for a covering. This, however, being the usual 
treatment at the time, did not strike horror to the public 
mind. 

The treatment of the insane from a humanitarian 
point of view has advanced very much since those days. 
We do not now chain our lunatics to the floors, the walls, 
the tables, and the bedposts ; we do not keep them naked 
on straw, wallowing in their own filth ; or flog them 
periodically as a curative measure. Every kindness and 
consideration is shown to these unfortunate beings. 
Everything is done in asylums to render the lives of 

15 



16 INTRODUCTION 

the inmates brighter and more pleasant. Fields and 
workshops afford facilities for work and wholesome 
recreation, and attendants are trained to a better un- 
derstanding of their patients. 

Yet in view of the fact that nowadays we recognise 
the earliest signs of insanity and have to treat these, as 
well as many borderland cases, it is surely a hardship 
that patients who are not in the least dangerous, and who 
are not likely to commit any folly, should have to be 
certified and imprisoned in an asylum. The Lunacy Law 
decrees — no matter how harmless and innocuous the form 
of insanity, how amenable to treatment in private care, 
or how mild the delusion, if any — that all persons of 
unsound mind shall be deprived of their liberty. Un- 
doubtedly this is necessary in many cases, but in many 
others it retards, if it does not prevent, the recovery of 
the patient. 

My experience of seeing patients in private practice 
and as out-patients, and in Continental Observation 
Clinics, has convinced me that there are a large number 
of cases which, with appropriate treatment, recover so 
rapidly that asylum residence becomes unnecessary. But 
if this period is neglected, and the case has reached a 
point where the patient must be certified, a much longer 
time is needed for recovery, and sometimes it is altogether 
too late to cure. 

The intention of the law is of course to prevent 
patients from doing harm bodily, financially, or other- 
wise, to themselves or others, as well as to protect them 
from their own follies and the dishonesty of the unscru- 
pulous. Hence all patients are put under the control of 
the Lunacy Commission. To secure this protection it is 
necessary under the present law to obtain a certificate 
of insanity, however slight the mental disorder of the 
patient, which certificate, unless the matter is urgent, 
must be signed by two doctors and confirmed by a 
Justice of the Peace, or Magistrate, who grants an order 
for the patient to be removed from his house, if necessary 
by force. He may then be put under lock and key 
in an asylum. The only exceptions are those patients 
who themselves desire to go into asylums as " voluntary 
boarders," and those patients whose relatives have the 



INTRODUCTION 17 

means to put them in " single '* care under the charge 
of some one directly responsible to the Commissioners of 
Lunacy. 

In no other form of disease is " appropriate " treatment 
so tardily initiated and so difficult of attainment. Even 
the expert is hampered to an incredible extent. It is 
illegal to place any patient of unsound mind, even if 
he or she be under twenty-one years of age, under care 
and treatment for payment, direct or indirect, or even 
for residence only, unless the whole process of " certi- 
fication " is gone through. The physician has to incur 
the responsibility that the patient, who in his judgment 
may be merely a borderland case and not certifiable, 
may be considered by the Lunacy Authorities to be 
insane ; in which case he would be prosecuted and have 
to pay, in addition to the costs of his defence, a consider- 
able fine, even though he attended the patient gratuitously. 
True, prosecutions of physicians for not observing the 
Lunacy Laws are extremely rare. But this proves only 
that in the application of the laws there is less stringency 
than is in their wording, and that, provided the physician 
has acted " in good faith " and is of good repute, no 
public action will be taken. 

If the relations of a rich man cannot procure treatment 
for him without certification, the case for the poor man 
is still worse. If a poor man breaks down, it is very 
difficult to procure treatment for him until he is bad 
enough to be sent to an asylum, though he may be 
wishful to place himself under care. He could not even 
be admitted to the County Asylum as a voluntary 
boarder. No hospital would take him because he had 
no organic disease, no asylum because he was not certi- 
fiable. Thus in the majority of instances the case is 
allowed to drift until overt acts of insanity appear. 
The Relieving Officer is then consulted, and the patient 
removed to the workhouse infirmary, where after a delay 
of a week or two the patient is certified, and subsequently 
transferred to the County Asylum. This procedure is 
unsatisfactory, and involves serious delay in employing 
effective treatment. 

It is no exaggeration to say that in the great majority 
of cases the curable stages of insanity are not being 



18 INTRODUCTION 

treated, and that by the time asylum physicians see the 
patient, the disease has made such progress that the 
measures which could have been adopted in the early 
stages are of little avail. 

" Certification " is an absolute and indispensable 
preliminary to treatment. Not that the certification 
itself is objectionable. It is the simplest and safest 
method of recording the medical opinion that the person 
is insane and a proper subject for detention and treat- 
ment. At the same time it must be remembered that 
it is very disastrous for a patient's future prospects to 
have it known that he has been certified and treated in 
an asylum. He is shunned, and perhaps feared by his 
friends, and possibly never again attains the status 
possessed before he was " certified/' Of course, the 
stigma to a great extent lies in the misfortune itself, 
and not in the red tape of the proceedings. Small 
wonder, then, that the public as well as many family 
physicians hesitate before they allow a patient to come 
under the ban of the Lunacy Laws and have him pro- 
nounced a " certified lunatic " ! To the expert this is 
merely playing with words, but it cannot be denied that 
to the general public it spells disgrace. It means loss 
of social and domestic rights, deprivation of all civil 
rights, separation from wife, family, and home, and if 
the patient does recover, he is for ever afterwards branded 
— " He was once a lunatic." It is the right which the 
certificate confers to remove a patient by force to an 
asylum who is still curable by other means that is ob- 
jectionable to most people. If the patient is not bad 
enough for the asylum, the committal is apt to make 
him so. There may be resistance and a struggle at the 
time, or if transferred under a " ruse," the patient, on 
recognising where he has been placed, is apt to cause a 
scene, and become either violent or still more depressed, 
according to the nature of his mental trouble. 

Imagine the misery of the patient who has any reason 
left when he finds he is a prisoner locked into a room 
by himself or, worse still, confined with other lunatics 
of all descriptions, generally more insane than himself. 
Let any one think what an asylum is, and what a sensi- 
tive person must feel at being imprisoned in it ! Let 



INTRODUCTION 19 

him realise also that many of its inhabitants have become 
insane simply because they are too sensitive. They can- 
not bear wrong and sorrow and disappointment, and 
resent what they believe to be an injustice. Imprison- 
ment in an asylum is regarded by such patients as an 
additional wrong. They shrink from association with 
the mad people by whom they are surrounded. If per- 
chance they lose the remembrance of old fears and 
anxieties, new and fresh ones soon accumulate in a 
place where they are so much dependent on others, and 
where discontent and despondency are the prevailing 
tones. There can be nothing more calculated to hinder 
their recovery than to limit the intercourse of the insane 
to those who are themselves insane, yet this is unavoid- 
able in asylums, where the only rational persons with 
whom the patient regularly and freely associates are his 
attendants. Even the pleasures and exercises can only 
take place with numerous other fellows in misfortune, 
whose language and conduct would fill even less sensitive 
and timid people with alarm. The mere aggregation 
of so many distressed beings of different types under 
one roof is a disadvantage, as patients have to hear 
and share numberless griefs in addition to their own, 
and many painful delusions are suggested to them which 
might otherwise never have entered their own minds. 
The majority of new patients feel this acutely, and 
experience great difficulty in throwing off their mental 
troubles in consequence of the many depressing circum- 
stances and incidents which surround them. The 
locked doors are a torture, and the scenes which are apt 
to occur when patients are forcibly fed exercise a bad 
influence on those who have never seen or imagined 
anything of the kind before. The monotony of existence, 
trying even to the staff, cannot fail to be something 
approaching absolute torture to those patients who have 
sufficient intelligence to note the passage of time. Even 
the sports and games in an asylum become wearisome 
to those who have nothing else to do. In the case of 
those unaccustomed to depend on books, the intelligence 
must also be starved when placed in circumstances 
where they can take little or no interest in the daily 
life around them, and their affections are killed by 



20 INTRODUCTION 

the unvarying, chilly, and even hostile influence of 
confinement. 

The patients for whom lunatic asylums are particu- 
larly deleterious are those who display the milder forms 
of mental derangement, those who are capable of reason- 
ing logically in regard to most of the circumstances pre- 
sented to their minds, and are able to control themselves. 
Such persons feel very acutely the injustice and disgrace 
of incarceration. They know they are not dangerous to 
themselves or others, and the deprivation of their liberty 
they regard as cruel and uncalled for. 

Moreover, there are a considerable number of persons 
who are certified as lunatics throughout the country who 
are simply suffering from temporary insanity, the result 
of, or associated with, some form of bodily disorder or 
toxic poisoning. Some of these people would have a 
much better chance of recovery in special wards of a 
general hospital than in a lunatic asylum. 

I maintain that there are very many persons who are 
of unsound mind, but who have no right to be treated as 
lunatics, and I have no hesitation in stating that at the 
present day there are amongst those incarcerated in 
asylums a large number who could be well managed 
outside. I have proved this in numerous cases. I have, 
in many instances, been the means of obtaining the 
freedom from asylum supervision of those who, apparently, 
had there been no intervention, would have been there 
for their natural lives. I do not recollect one single case 
where the steps taken were not followed by good results. 

It would be wrong, however, not to acknowledge that 
the British institutions for the insane are model insti- 
tutions, well designed, perfectly governed, and admirably 
conducted. Nor will any one deny that there are cases 
— even in the early stages of insanity — where an asylum 
is useful, and others where it is indispensable. Just 
as we must have hospitals for the poorer classes, so we 
must have asylums for paupers, or for those living in 
wretched homes where they would be neither properly 
watched nor carefully fed ; but there are other cases 
for which the asylum is eminently unsuitable, and 
positively harmful. Circumstances may be such that 
some place where the lunatic can be kept in safety is 



INTRODUCTION 21 

absolutely requisite ; but it is not always necessary to 
confine him in an asylum, though it may be necessary 
to place him in such a situation as will secure his safety 
and, in all cases, where he will have careful nursing and 
skilled medical attendance. 

Asylums we must have, and for some patients there 
is no better place ; but there are others for whom we 
require new institutions, more in the nature of hospitals, 
and extended powers for private treatment. (See 
Chapter XIV.) 

I do not think I am wrong in saying that in view of 
the powers of the Lunacy Commission some medical 
practitioners have a wholesome dread of being in any 
way mixed up with the certification of an insane person 
or even of attending him privately. Another reason 
for this reluctance on the part of the family physician, 
and why insanity is neglected in the early stages, is that 
a good many medical practitioners feel that they are 
not sufficiently competent to treat an insane patient. 
The treatment of insanity requires an intimate know- 
ledge of the structure and functions of the brain, of 
normal and abnormal mind and character, and special 
experience of the practical affairs of life ; but the 
subject has, up to a few years ago, not been included 
in the medical curriculum, so that the vast majority of 
the older practitioners have had no opportunity what j 
ever of acquiring a systematic knowledge of it. And 
even now, though the study of insanity has been made 
compulsory to medical students, it occupies a compara- 
tively insignificant position, so that a mere smattering 
of knowledge of the subject is all that can be acquired. 
Hence the first signs of insanity of ten fail to be recognised, 
not only by the public at large, but also by medical 
practitioners, or, if recognised, are under-estimated. 

Another reason for the delay in treatment is that, 
unfortunately, the public believe that most specialists 
own private asylums, or are sleeping partners in such 
concerns, or are in some friendly relation to their proprie- 
tors. Hence there is a fear, though absolutely unjustified, 
that patients who consult these specialists may be sent 
too readily to their institutions when other measures may 
still be adopted. So great is this fear of being sent to 



22 INTRODUCTION 

an asylum as the result of consulting a lunacy specialist, 
that the public avoids a visit until compelled by dire 
necessity. It is only in the last resort, when all other 
means are exhausted and the mental breakdown is com- 
plete, that an alienist is consulted. This undesirable 
state of affairs will continue so long as consulting lunacy- 
physicians are allowed to have financial interests in 
private asylums, and until the public is made aware 
that the specialist has some definite treatment to propose 
besides certification and confinement within locked doors 
and barred windows. 

What the insane require, notwithstanding their in- 
sanity, is association with healthy minds. And this is 
out of the question in an asylum. The patient, if not 
inclined to work or play, is left to indulge in his fixed 
ideas and delusions, which therefore tend to become more 
fixed than ever. 

Whatever curative influence the asylum may possess, 
the one thing that could have saved the patient it 
cannot supply, and that is " individual ' : treatment. 
For what personal attention can a patient receive in an 
asylum, even when there is a so-called hospital annexe, 
when a thousand or more patients have to be visited by 
the superintendent and two or three assistant medical 
officers. No one can deny that the majority of asylum 
physicians are able men, but I do not think it possible 
for any man, however clever and however eminent in 
his profession, to treat a thousand patients as he would 
wish to treat them. 

The insane, like ordinary men, have their bodily 
ailments, and the treatment of these must take up a 
good deal of the physician's time. Further, in such vast 
concerns, the mere clerical work is very considerable, 
not to speak of the keeping of medical records and atten- 
tion to correspondence. The medical superintendent is 
not only a doctor, but he is the head of a great estab- 
lishment embracing gardens and a farm, as well as 
the staff and buildings of the asylum itself. Of course, 
" where there's a will, there's a way," and it is not true 
of all asylum medical officers that they have no time for 
scientific work because of their administration duties. 
Those who have achieved the most in the speciality 



INTRODUCTION 23 

have not always been those who have leisure, but the 
busy, the willing, and the determined. Although hin- 
dered often by imperfect structural arrangements, over- 
crowding, and inability to divide the patients into 
small enough groups, efforts have been made to classify 
them in accordance with various specific needs. In 
recent years more tangible provisions for classification 
may be seen in special buildings for the study of the 
new cases, and for the treatment of the more acute 
conditions, which have been added at many institutions, 
in special wards or buildings for general hospital pur- 
poses equipped for the treatment of those suffering from 
acute physical illnesses and surgical conditions, and in 
infirmaries for the feeble and bed-fast. For the better 
personal care and nursing of the patients, training-schools 
for nurses have been established. Still, the managing 
committee value the superintendent for the sake of his 
qualities as a manager, administrator, and organiser, and 
only secondarily as a skilled physician. 

No wonder that the recovery rate of the present 
day in the most comfortable and luxurious palaces for 
the insane and under the most humane treatment is 
no greater than in the days when strait-jackets and 
rough treatment were freely used in badly furnished 
asylums. The surroundings, the comfort, and the care 
of the patient do affect his behaviour and modify his 
symptoms, but they have no effect on the disease itself. 
Mental disorders, once they have reached the acute stage, 
will run their course, and whether they end in recovery, 
or become chronic, or end in death, does not depend on 
any treatment in an asylum which a hospital or an 
efficiently organised private home could not supply 
just as well. On the other hand, for the majority of 
inmates, chronic and incurable cases that no treatment 
will ever improve, the palatial character of the building 
in which they are immured affords no delight, and the 
elaborate and expensive organisation is entirely thrown 
away. 

The operation of the Lunacy Laws has made it neces- 
sary to herd lunatics together in special institutions 
where they can be more easily visited and accounted for 
by the authorities. The result of this is that there has 



24 INTRODUCTION 

grown up a body of men who are directly responsible to 
these authorities for the confinement and detention of 
the insane. 

It is a feature of the Asylum Medical Service that men 
enter it early in life, and grow up subject to its conditions. 
Men, just qualified, are chosen as junior officers, and 
are gradually promoted, either in the same asylum or 
some other in which an opening may occur. No one 
is chosen as a senior officer, whatever his qualifications 
for the treatment of mental disease, unless he has had 
asylum experience. In other words, the future super- 
intendent must not only have been put into the groove 
early in life, but he must have remained there. Dr. 
Conolly was the only physician, to my knowledge, who 
was ever chosen as superintendent without such experi- 
ence, and it was he who abolished at Han well Asylum 
the employment of mechanical restraint, of fetters and 
shackles for the insane — an example which has been 
universally followed. 

With the constantly increasing size of asylums it is 
no doubt essential that only such medical officers should 
be selected who have experience in the routine work of 
these large establishments, and it is entirely to their 
credit that of late years much valuable work has been 
done, especially in those asylums which are provided with 
laboratories. We have learned more about the structure 
and pathology of the brain during the last twenty or 
twenty-five years than in the hundred years that had 
gone before. Whatever may be said against the asylum 
system, it must be admitted that the conductors of them 
are disinterested and many of them brilliant men, and 
that they are the first to admit the advantages of early 
treatment of the insane. The only difference of opinion 
is that some desire an extension in the organisation of 
asylums to that effect, and others are in favour of special 
hospitals and observation wards. 

As regards private asylums, one serious grievance is 
that their owners can refuse admission to the consultant 
who comes to see whether the patient is well enough to 
be removed to more favourable surroundings. If the 
visit does not suit the proprietor, he can respond that 
there is no occasion for such interference, or that the 



INTRODUCTION 25 

patient will probably get worse from the visit. Or else 
the proprietor may suggest the name of some friendly 
expert, if not the actual sleeping partner of the concern, 
in place of the doctor proposed by the patient's friends. 
Perhaps this is seldom done, but it can be done, and that 
it should be possible is against the public interest and 
the intention of the Lunacy Law. After all, the pro- 
prietors of private asylums are human beings, with the 
same defects as the rest of mankind, and a " licensed " 
house for mental cases is as much a mercenary specula- 
tion as an hotel or large boarding-house. That there 
is little or no scandal with reference to them shows 
that they are as a rule well conducted, and that no 
person is detained unjustly, yet even the suspicion of 
such an occurrence should be made impossible. 

Of course, there are doctors and " doctors/' and the 
proprietors of private asylums may plead that they 
refuse admission only to " cranks " and men disliked by 
their own colleagues. All the same, it would be more 
satisfactory if it were made compulsory on asylum 
superintendents to admit any qualified physician selected 
by the trustee or relative of a patient to visit him and 
report as to his personal condition, and that of his 
surroundings and treatment. 

But, it will be said, have we not Lunacy Commissioners 
to inspect these places and visit each patient ? Certainly ! 
And it is surprising the amount of work they do, and 
how efficiently they do it. We must remember, how- 
ever, that half a dozen commissioners — in January this 
year increased to eighth — have to visit and report upon 
133,000 lunatics in England and Wales in the course of 
a year, and that many of these have to be reported upon 
after personal inspection several times during the year. 
In 1845, when the Lunacy Commission was established, 
and its paid members were, as until recently, six in number, 
they had to visit only about 25,000 lunatics. It is a 
wonder the work is done so ably, and it speaks volumes 
for their indefatigable industry and solicitude. When 
one is personally acquainted with their work and has 
the highest esteem for every one individually, one is 
reluctant to say anything at all by way of criticism. But 
they themselves will acknowledge that some have only 



26 INTRODUCTION 

had legal training, and even those who are medical men 
have only been chosen for the post because of their 
asylum training, and that supervision of a hundred and 
thirty-three thousand insane, even if the number of Com- 
missioners were increased by half, would be impossible 
if the insane were not gathered together in large herds, 
but were in private or family care. 

The Commission was originally formed for the purpose 
of doing away with the possibility of illegal detention of 
persons who were not insane, and to prevent cruelty 
to persons so detained. But as regards public (county 
and borough) asylums, they only go once a year to see 
the general appearance of the patients and their relative 
contentment with their lot, and whether the place is 
clean and fairly decorated. Beyond that, there is no 
independent view, so that the individual patient cannot 
receive that attention which was originally intended, 
certainly not as much as if he was in private care. 

As regards the public asylums, there are other reforms 
needed, besides the recommendations of the recent Royal 
Commission on the Care and Control of the Feeble- 
minded. Whereas hospitals are open to all comers seek- 
ing study, research, or simply desirous of watching the 
work done there, the scientist in search of material for 
earnest work is met at the portals of the asylum with an 
emphatic negative. The forbidding frown of the adminis- 
trative bodies warns off the student who would fain enter 
the house of the afflicted for the purpose of earnest study 
and investigation. No helping hand is stretched out 
to welcome the scientific investigator who would devote 
his time to the study and perhaps amelioration of the 
condition of the unfortunates housed within the walls 
of the institution. Possibly it is held that the opening 
of the institutions for the insane to the visits of students 
and scholars would be a violation of personal privileges, 
but the student and the scientist are not curiosity 
seekers who come to watch the antics of the demented. 
These scholars are men and women who are moved by 
a noble impulse to devote themselves to a hard and 
thankless task. To place obstacles in their way is an 
indignity, and no amount of specious pleading can alter 
this fact. 



INTRODUCTION 27 

The English Lunacy Laws arose out of a series of 
regrettable incidents which occurred nearly one hundred 
years ago. I see no reason why they should not be altered 
so as to facilitate the treatment of the incipient stages 
of insanity. Why not, when there is already such facility 
in Scotland ! Half of the paying patients in Scotland 
are never certified as insane, but are treated by their 
own medical attendant in private houses, to whose pro- 
prietors the doctor gives a certificate authorising them 
to receive the patient. The responsibility rests entirely 
with the medical attendant. But then the Scottish 
Law did not arise from asylum scandals, but from the 
insufficient provisions for pauper patients by the ancient 
Royal Asylums of Scotland, so that a law was made 
establishing distinct asylums. It was made merely to 
improve the condition of the insane, whereas the English 
Law was conceived in a spirit of suspicion. 

Public opinion is unanimous, both in medical and lay 
circles, that the provision for the treatment of incipient 
insanity in England is inadequate, and that the treat- 
ment even by the most trustworthy and gifted medical 
attendant is hindered by legal obstacles. Insanity, al- 
though one of the most dreadful diseases in its conse- 
quences, is still a subject only superficially taught to the 
medical student, and still less understood by the lay 
public, however educated in other respects. It is only 
by early individual treatment that we can save the 
patient. 

It is the purpose of this book to show what insanity 
really is, how it can be prevented, and how it can be 
treated before it reaches the incurable stage. 



PART I 
THE FIRST SIGNS OF INSANITY 

MIND AND CHARACTER, NORMAL AND ABNORMAL 



CHAPTER I 
WHEN IS A PERSON INSANE? 

The study of the first signs of mental disorder is of 
immense importance to mankind, inasmuch as it leads 
to the prevention of a disease which robs man of all 
his highest and proudest attainments. The first signs 
of insanity, as has already been explained, are rarely 
seen in asylum practice, which is of necessity restricted 
to the advanced stages, since only " certified " patients 
can be admitted to licensed institutions, and the 
patients who seek voluntary admission are very few 
in number. Statistics show that on January i, 1911, 
there were 133,157 certified insane residents in asylums 
and in private care in England and Wales under the 
jurisdiction of the Lunacy Commission — that is, 1 in 274 
of the population. We have no statistics to prove how 
large is the number of the medically insane individuals, 
whose insanity is known only to themselves, and perhaps 
to some of those who are in intimate social relations 
with them, who have lost none of their rights, privileges, 
or responsibilities as citizens, who transact their business 
with fidelity and accuracy, and yet are as truly insane, 
though in less degree, as any of the inmates of asylums. 

If to the number of insane we were to add the number 
of imbeciles and weak-minded people, the figures would 
be truly appalling. According to one authority, at 
least 1 in 217 of the population — quite independent of 
the number of lunatics — is mentally defective, that is, 
either idiot, imbecile, or feeble-minded, and when children 
on the school registers are considered, the proportion is 
still higher — namely, 1 in 127. 

Many insane people are tolerated in the community 
because it is not worth any one's while to interfere with 

31 



32 THE FIRST SIGNS OF INSANITY 

them, and they do not seriously interfere with the social 
current. But when, for various reasons, they become 
troublesome, or commit an indiscretion which affects 
their own existence or which brings discredit on their 
family and friends, they are declared " legally " insane. 

Medicine deals with disease, and the law with be- 
haviour. What the law takes cognisance of is not 
whether a person is unsound in mind, but whether the 
person is insane in conduct or likely to become so. About 
his thoughts and feelings it is not concerned in the least, 
so long as no harmful conduct is likely to arise from 
them. Whatever a person believes, thinks, or feels 
matters only in the medical estimation of insanity. In 
the legal sense it is of no consequence, so long as his 
conduct is not affected thereby. It is for what he says 
and the way he behaves that a person is " certified " 
as insane. It is the patient's lack of self-control and 
inability to adapt himself to his environment which is 
the criterion of admission to the asylum. Thus in such 
institutions we get those types of cases together which 
appear forbidding to the ignorant and to whom the 
antiquated term of "lunatic" is applied. 

A patient may be certified whenever his conduct be- 
comes unsafe to himself or to others. When the realm 
of conduct is invaded, then the disease becomes of social 
importance and can be certified as insanity. Thus, 
what was before medically true, though legally denied, 
is admitted only when the preliminary and most curable 
stage has passed. It is the badly damaged brain that 
is sent to the asylum for safe keeping, but there are, in 
every stratum of society, large numbers of blemished 
brains that perform their functions irregularly, and 
require repair. 

Insanity seldom comes like a thunderbolt out of a 
clear sky. The study of insanity clearly shows that it 
practically never develops in a day, but that, on the 
contrary, often weeks and months elapse until the devia- 
tion from normal mental health is noticed. Often some 
accidental circumstance, some apparently trivial event, 
may be the determining cause of the outbreak — the 
immediate precursor of the declared symptoms ; but 
the conditions have been there before, and, as in the 



WHEN IS A PERSON INSANE? 33 

old adage, the new event was but as "■■ the last straw " 
that made the burden intolerable. 

If the early history of the patients be only carefully 
investigated, it will be found that eccentric acts on their 
part took place long before the actual outbreak of the 
disease. If only such patients had chosen some quiet 
pursuit in life, and if their conduct had been closely 
watched by their relations, much trouble and expense 
connected with their mental disease would have been 
prevented. Opinions may differ as to how wide may 
be the departure from normal to justify us in diagnosing 
insanity, but yet this is the beginning of the malady ; the 
difference between this state and certifiable insanity is 
a quantitative difference, a difference of degree only. 

There is no sharp demarcation between medically and 
legally insane. There are no hard-and-fast lines separating 
sanity and insanity, soundness and unsoundness of the 
mind ; indeed, there is no sharp division between health 
and disease in general, disease being nothing more than 
an exaggeration, or disproportion, or inharmony of 
normal phenomena. There are a very large number of 
cases of mental disturbance which are very slight and 
not decided or specific in their character, and which may 
be described as on the " borderland." This stage is the 
one where suitable care and treatment are most effective. 
Many a man and woman if rightly treated in the border- 
land would go no further, and never be reckoned as 
having been mentally unsound at all. 

Whereas the general diagnosis of insanity, when once 
pronounced so as to necessitate certification, is in many 
cases so easy that it can be made by any layman, the 
early stages of mental unsoundness often demand all 
the science and skill of the most experienced observers. 
Even in the domain of physical disease, where exact 
physical means for diagnosis are at hand, it is often 
difficult to decide where health changes to disease. 
How much more difficult must it be, then, in the psychic 
domain, where a standard of mental health can only 
be thought of as ideal ! How much more difficult must 
it be, where no individual is exactly like another, and 
variations of thought and feeling from the majority of 
mankind, and even errors of the understanding and 



34 THE FIRST SIGNS OF INSANITY 

illusions of the senses, are possible within the limits of 
physiologic life ! 

In reference to the body, " feeling well " is the chief 
mark of health ; most people who are sick know it. 
With the mind it is otherwise ; here there is no con- 
nection as between health and feeling well, and the 
patient is not in a condition to say whether he is well 
or not. Consciousness of derangement occurs, as a 
rule, only at the very beginning of insanity, and that 
only in some patients ; and it occurs again just before 
recovery, when the knowledge of being mentally ill is 
one of the most marked symptoms of convalescence. 

At the approach of insanity the unfortunate sufferer is 
often conscious of a gradual loss of control over his 
thoughts, feelings, and fears, but he conceals with the 
utmost jealousy from his relatives and friends the agony 
that is eating into his very soul. No doubt innumerable 
acts which puzzle and appear totally unaccountable to 
friends and strangers, are the result of mental conflict 
hidden in the depths of the patient's mind. In such 
cases the demon in possession seizes those very moments 
in which the enjoyment of other men is found. At the 
festive board, in conversation with friends, in the company 
of ladies, when everything is couleur de rose, this conflict 
will sometimes rage fiercely and incite the sufferer to 
sudden movements, or subject him to fits of abstraction 
which startle and confound those who watch his conduct. 

Persistent introspection or gloomy retrospection, 
excessive sensitiveness, marked egotism, a feeling of 
unsettledness, a want of power of continuous application 
to the usual occupations, are all characteristics not to 
be lightly regarded. A prolonged condition of want of 
conscious energy, when work ceases to be a pleasure, 
when there is "no go" in the man, is a symptom to 
be taken notice of. The opposite condition of causeless 
impulsive action and continuous output of energy without 
sufficient cause is also sometimes suspicious. In persons 
who have had normal or extra good manners when in 
health, it is a bad sign if the usual social observances 
and conventions become markedly irksome — and are 
departed from. 

Of course, none of us reach the ideal in mind and 



WHEN IS A PERSON INSANE? 35 

conduct, and some have marked peculiarities. It has 
been said that " nearly all the world is cracked," but 
some succeed in concealing the crack better than others. 
So cleverly and successfully is the mask of sanity and 
mental health sometimes worn, so effectually is all 
suspicion disarmed, that mental disorder of a dangerous 
character has been known for years to be stealthily 
advancing without exciting the slightest notion of its 
presence, until some sad and terrible catastrophe, homi- 
cide or suicide, has painfully awakened attention to its 
existence. 

In the incipient stage of insanity the patient is some- 
times fully sensible of entertaining exaggerated and 
unnatural impressions ; he is acutely conscious of the 
mind dwelling morbidly and sometimes irresistibly upon 
certain trains of absurd, unhealthy, and it may be very 
impure thoughts ; he painfully recognises the fact that 
insane conceptions are struggling to master' his reason, 
obtain an ascendancy over his judgment, an abnormal 
influence and control over his passions, and the subjuga- 
tion of his instincts. 

The difference between sanity and insanity consists 
in the degree of self-control exercised. We all have, at 
some time or other, thoughts passing through our 
minds and feelings agitating us which, if they were 
expressed and indulged in, would be as wild and perhaps 
as frightful in their consequence as those of any mad- 
man. But the man of strong mind represses them, and 
seeks fresh impressions from without, if he finds that aid 
needful. The man of . weak mind yields to them, 
meditates on them, indulges in them, and thus they 
acquire fresh force, until he is totally unable to free 
himself from the thought or subject that haunts him, 
and he is then insane. 

The time that a patient remains on the borderland 
of mental disturbance varies enormously in different 
cases. One man, by reason of innate brain instability, 
may be in this condition almost all his life ; another 
may only be so whenever he experiences any severe 
stress, mental or bodily. In another case the mental 
condition only becomes disturbed when there are violent 
mental cataclysms or a prolonged condition of bodily 



36 THE FIRST SIGNS OF INSANITY 

or nervous exhaustion, or during the presence of some 
bodily disease accompanied by blood-poisoning. 

The standard of sanity depends partly on the en- 
vironment, which varies not only with every stage of 
civilisation and barbarism, but also with each social 
station and each grade or phase of education. What 
would be natural and commonplace in one state of society 
or in one community, would be altogether aberrant and 
unusual in another, and this difference exists even in the 
same persons under various circumstances. 

The standard of sanity depends also on the standard 
of the individual. Every one thinks and acts in his own 
way, and thus there is formed a special standard of 
normality, which is made up of habits, social instincts, 
education, training, and more especially of those moral 
traits that constitute what we call character. In these 
respects the individual must be measured by the standard 
of his own personality— he must be tested by what he 
ought to be and by what he was in his normal con- 
dition — before an accurate decision can be arrived at 
in any case of suspected mental disorder. 

Insanity may therefore be described as a symptom 
of derangement, disease, or defect of the brain, causing a 
disordered action of the mind and putting the subject into 
a condition varying from his normal self and frequently 
out of relation to his environment. 

It is the brain which is at fault, that part of the 
nervous system upon the unimpaired condition of which 
the exercise of the understanding and the proper 
manifestation of the feelings and instinctive propensities 
depend. The brain itself may be diseased, or it may be 
affected indirectly ; the blood with which it is supplied 
may be defective, or, since the brain is intimately 
connected with all the bodily organs, their disturbed 
condition can cause a reflex-irritation of the brain. 

In many cases the symptoms of insanity are due to 
functional disorder of the brain. Those insanities which 
are organic, like progressive paralysis, senile dementia, 
etc., are incurable, at all events at present. 

The general practitioner must remember that mental 
diseases are brain-affections, with predominating, but not 
exclusive, psychic symptoms. Even though the recog- 



WHEN IS A PERSON INSANE? 37 

nition of the latter is essential for a judgment of the 
mental condition, still the diagnosis must not depend 
upon that alone. Other possible signs of existing cere- 
bral and nervous disease must be investigated. Mental 
diseases are accompanied by disturbance of the vegeta- 
tive life. Specially important physical symptoms are 
disturbances of sleep, of nutrition, or secretions, and of 
the functions of digestion. Most careful examination 
of the bodily organs and their functions must go hand 
in hand with mental examination, whenever possible. 

It is of great importance also to be able to observe 
the patient under his ordinary circumstances of life ; 
the manner in which he lives, dresses himself, and employs 
his time may afford important elements. It is neces- 
sary to know not only what questions to ask, but also 
how the conversation should be directed. During the 
examination the gestures and demeanour should be 
observed, as well as his home and surroundings. 

In mental derangement the primary disorder usually 
consists in a tendency to disordered emotional excite- 
ment, which affects the course of thought and, conse- 
quently, of action without disordering the reasoning 
processes in any other way than by supplying them with 
wrong materials. Men seldom, if ever, go mad from 
intellectual activity, if it be unaccompanied by emotional 
agitation. We confine people as lunatics, not because 
their reasoning is unsound, but because the play of 
motive in their minds is too abnormal for us to rely on 
it. Thousands of people believe absurdly enough that 
they have been wrongly treated. That does not make 
us interfere with them, but when extravagant vindictive- 
ness appears, when the individual goes about to shoot 
imaginary persecutors, he is classed among the insane, 
though his intellect may still be capable of profound or 
brilliant work. 

In the earliest stage of insanity no intellectual defect 
may be apparent. The reasoning power may remain 
clear, the intellect as bright as ever, and in the course of 
a long conversation friends may not perceive the slightest 
cloud on the understanding. Or if there be any in- 
tellectual defect, it is displayed in the inability to re- 
cognise and realise the impropriety of the conduct. If 



38 THE FIRST SIGNS OF INSANITY 

one remonstrates or reasons with such a patient, one 
is astonished at the astuteness with which he justifies 
and accounts for his conduct. 

It is in actual brain-degeneration, and not in any 
of the lighter forms of insanity, that the intellect shows 
permanent signs of weakening. In such cases we get 
other signs and symptoms as well that leave no doubt 
as to the progressive nature of the disease. These 
we shall describe under the varieties of insanity (Part IV). 
Before doing so we must first seek some acquaintance 
with the science of the phenomena of mind and the 
evolution of the primary mental powers to help us to 
understand their derangements. 

Whether the brain is affected directly or indirectly, 
something has happened to hinder its normal function. 
The personality of the affected person is altered, some- 
times by an alteration of character contrasting with 
the ordinary healthy condition, sometimes by an ex- 
aggeration of the natural dispositions and predilections 
which had marked the individual when in health. 

When there is an alteration in the character, the change 
is generally in the direction of degradation. The kindly 
and forbearing man becomes irritable and quarrelsome ; 
the refined and gentlemanly man consorts with people 
very much beneath him regardless of their character ; 
the prudent man launches out in wild speculations ; the 
previously orderly and economical man becomes con- 
fused and prodigal ; the precise man exhibits carelessness 
and negligence ; the gay man is sullen and morose ; 
and the modest, retiring man thrusts himself forward 
into all kinds of society, writes long and familiar letters 
to persons with whom he has only a bowing acquaintance, 
asking favours, offering benefits, and making appoint- 
ments ; the parsimonious man becomes lavish, and the 
generous man parsimonious. Often there are also 
aversion and antipathy towards persons who previously 
were regarded with respect and affection ; a change so 
painful to those towards whom it is manifested that 
it is usually the earliest to be noticed. 

When there is an exaggeration of the natural dis- 
position, previous faults of character and of temper 
manifest themselves in greater intensity, over-sensitive- 



WHEN IS A PERSON INSANE? 39 

ness passing into melancholia, suspicion into delusion, 
irritable temper into uncontrollable violence, weak 
volition into obsession, the talkative man monopolising 
the conversation more completely than usual, the 
uxorious man becoming even more demonstrative, the 
egotist bragging more audaciously, the querulous man 
complaining more bitterly, the naturally timid and re- 
served man shunning society and isolating himself 
altogether from the companionship of his family and 
friends, the bold man becoming noisy and presuming, 
the courageous becoming officious and talkative, and the 
strictly upright person exhibiting an unhealthy exalta- 
tion of conscience respecting his moral and social duties. 
Any peculiarity of conduct which is natural and not 
assumed becomes exaggerated. 

Through habit a faculty may become so powerful 
that we lack strength to control it ; it controls us. All 
habits and powers, all passions and propensities, are 
liable to grow by exercise ; every one of these irregularities 
may, by cultivation and indulgence, become strong 
enough to overcome the reason and cut off the means 
of correcting mistakes in judgment, and thereby establish 
insanity. 

All the evil passions — anger, violent temper, hatred, 
malice, envy, and jealousy — are even more injurious 
to the balance of the mind than any of the intellectual 
disproportions. A man in a passion sees in the object of 
his anger those qualities, and only those, which he wants 
to see, and his imagination fills up the rest with such 
as correspond to his own state of feeling. He clothes 
his antagonist in a garb of his own creation, and then 
finds undoubted proof that he is wronged. 

Those whose insanity is only an exaggeration of their 
previous state are persons with an insane diathesis or 
temperament — a very small matter suffices to throw 
them off their normal balance. They break down, 
perhaps without any apparent reason, recover, and 
break down again, and pass often into a state of recurrent 
insanity which may last through a long life. 

There are, therefore, two classes of insane — those 
whose character has undergone a change and those 
whose natural characteristic has become accentuated or 



40 THE FIRST SIGNS OF INSANITY 

exaggerated beyond control. In judging a man's sanity, 
it may, consequently, be as essential to know what his 
habitual manifestations were as what his present 
symptoms are. The degree at which this departure 
from the natural and healthy character, temper, and 
habits ought to be held as constituting insanity is a 
question of another kind on which we can scarcely hope 
for unanimity of sentiment and opinion. 

Of course, it is not the temporary change, the tem- 
porary mood or exhibition of eccentricity, which con- 
stitutes insanity ; for then those only would be considered 
to be sane who possess ordinary level minds and no 
originality to go out of the beaten track. There are few 
among us who have not moments of depression or of 
abnormal excitement, fits of anger or fits of extravagance. 
It is the prolonged departure, without any adequate external 
cause, from the state of feeling and mode of thinking usual 
to the individual when in health that is the true feature 
of disorder of the mind. 



CHAPTER II 
DISORDERS OF THE ANIMAL PASSIONS 

Some knowledge of the mind and character of man, of 
psychology and ethology, is absolutely necessary in 
order to describe accurately the phenomena of morbid 
mental states. 

No two persons think, feel, or act in the same way ; 
no two take the same view of any question ; no two 
can be said to observe the same object in an identical 
manner or from the same standpoint. The intellect 
of each works on different lines according to inherited 
proclivities, individual experience, and education. It 
is this which forms the basis of distinctive individual 
personality. Though there are no two human beings 
alike in their mental constitution, in their abilities and 
character, yet the primary mental powers are alike in 
all, and the difference lies in the strength of each of them 
and the variety of their combination. All the differences 
of individual minds resolve themselves into differences 
of degree among the same identical qualities. 

Mental diseases, although they may be associated 
With the most serious complications affecting the in- 
telligence, do not create new and special desires, but 
merely rekindle in an extraordinary way and inflame to 
pathological intensity the common passions of mankind, 
such as anger, fear, lust, etc. 

We shall proceed on a proper psychological basis 
and study the various primary mental powers in order 
of their evolution. Having first explained their normal 
function in a healthy mental state, we shall then show 
their morbid activity in a state of disease, and finally, in 
Part IV, describe the various forms of mental disorder 
in which these primary powers are all involved. Some- 

4 1 



42 THE FIRST SIGNS OF INSANITY 

times only one or a group of them will show characteristic 
activity, sometimes another group will be the most 
distinct, and yet at another time mental activity may 
oscillate between the two groups. As the mental dis- 
order progresses, so all those activities become involved 
and disorganised until we have a state of dementia, a 
state of hopeless disorganisation. 

This method of unravelling the mysteries of insanity 
by first analysing the mental powers that make up 
mind and character, and describing them in their evolu- 
tionary order, seems to me preferable to the method 
generally followed in text -books, as more natural, logical, 
and easier of understanding. 



First of all, there are a number of elementary disposi- 
tions which we possess in common with animals which 
are aroused spontaneously and are implanted by nature 
for the preservation of the individual. 

Man being planted in a world, the inhabitants of which 
devour one another, the first law is the law of self-pre- 
servation. The " love of life " gives us certain energies. 
In insanity, especially in melancholia, this love of life is 
often abolished and leads to attempts at suicide 

(Chapter XIX). 

* * * 

In order to maintain existence, the animal must first 
of all search for that which will maintain life, it must 
destroy or kill for food. It is this appetite for food 
which directs man, even when new-born, to remove the 
pain of hunger and thirst, the only pain then removable 
by an act of his own. Of all the phases of conduct, the 
prehension of food is the simplest, the most important, 
the most fundamentally necessary, the first to appear 
in the race and in the individual, and the last to dis- 
appear with the failure of life or of sanity. The abuse of 
this instinct leads to gluttony and drunkenness. The 
insatiable craving of hunger, even when the stomach 
is full, is a common lunatic symptom. Some, having 
devoured their own ample allowance, seize upon all they 
can lay hands on, prowling about the entire day in 
search of food. We also find sometimes morbid desires, 



DISORDERS OF THE ANIMAL PASSIONS 43 

longings, or impulses for various substances generally 
regarded with loathing and disgust. 

Similarly, drink may become a mania (see alcoholic 
insanity, Chapter XXIII). Temporary alcoholic ex- 
cesses may be observed also in the excitement of hypo- 
mania (Chapter XVIII) and general paralysis (Chapter 
XXII). Persons of a neuropathic constitution in a state 
of exhaustion and psychic depression (Chapter XVI), 
and women in the change of life (Chapter XXIV), in 
order to overcome their irritable weakness, not in- 
frequently take to drink or to the abuse of morphine. 

Sometimes the insane refuse to take nourishment 

from a great variety of motives, according to the form 

of insanity. A patient may be immersed in his thoughts 

so that the sensation of hunger is deadened ; he may 

refuse it, because he fears it is poisoned ; another, 

because a voice told him that he must not touch it ; 

another, because he is too great a sinner to receive 

God's gift* In all we have the same symptom, but we 

have to trace the motive to arrive at a diagnosis of the 

mental disorder. 

# * * 

In order to maintain existence, the animal must 
moreover be able to remove the dangers by which it is 
surrounded, must prevent itself being destroyed, and 
be capable of inflicting injury on its foes. The funda- 
mental propensity to destroy is absolutely needful for 
the preservation of the individual. It matters not 
whether he fights only when danger arises or whether 
he meets difficulties half way, whether he fights with 
his teeth and nails, with his sword or pen, whether the 
attack be moral or physical, the same instinct is at the 
root of it all. 

One purpose of this propensity is the removal of 
objects that annoy us ; and as pain is an annoyance, it 
naturally calls forth the disposition to destroy whatever 
occasions it. Irascibility or anger is the emotion accom- 
panying the active form of the instinct of self-preserva- 
tion. It gives an impulse to inflict injury on the cause 
of the emotion. In order to overcome obstacles or to 
fight, great energy is needed. That the sight of its 
foes should arouse an animal's energies to furious rage, 



44 THE FIRST SIGNS OF INSANITY 

whereby spontaneously muscular changes are developed 
all over the entire body and the strength of every muscle 
is exalted, is due to a reflex mechanism of immense 
preservative value in the struggle for existence. Similarly, 
when a man gets angry, the spontaneous impulse is to 
inflict injury on the originating cause of the emotion. 

There is a thin border-line between the healthy and 
diseased manifestation of anger. Anger is short mad- 
ness, for the main characteristic of madness is loss of 
self-control, and this is exactly what happens to people 
in a passion. All considerations of reason and logic 
are thrown to the winds, the impulse of the moment 
is blindly followed, and words are said, actions done, 
which may do the gravest harm, yet while the person 
in a passion knows this, he is powerless to act otherwise. 
Persons who are habitually prone to outbreaks of anger 
become progressively unable to control their exhibition 
of wrath, and what to others are mere trifles, in them 
excite preternatural and fantastic storms of passion. 
The instinctive fury, the violent and destructive mania, 
of some madmen is only the same mental power acting 
in excess. 

Irritability of temper from slight causes, a tendency 
to take offence easily, noisy arguing, unpremeditated 
violence, and to a lesser extent designed violence, are 
common symptoms in several forms of insanity. Such 
manifestations in a mild form may be seen in the sane, 
but they occur more readily without adequate cause and 
are less under control in the insane. 

Slight irritability from exaggerated sensibility is 
common to neurasthenia (Chapter XVI). One of the 
characteristics of hysteria is instability of temper 
(Chapter XVII). Mere argumentativeness, rarely anger, 
is one of the symptoms of dementia prsecox (Chapter 
XXII). In hypomania (Chapter XVIII) patients be- 
come irritated on the slightest provocation, but their 
irascibility does not last. The general paralytic 
(Chapter XXII), too, may be easily roused to anger, 
and is also more or less easily calmed, at least in the 
early stage of his disease. Noisy, abusive, violent 
temper is seen in acute alcoholism ; unreasonable 
irritability, unprovoked anger rising to blind impulsive 



DISORDERS OF THE ANIMAL PASSIONS 45 

passion, is seen in chronic alcoholism (Chapter XXIII). 
Peevish disposition, bad temper, impulsiveness giving 
rise to dangerous acts, occur in epileptic insanity 
(Chapter XXV). 

The highest degree of irritability is seen in acute 
mania (Chapter XVIII), where we get excessive anger, 
violent language and conduct, sometimes lasting for 
days without any interval. Explosions of violence occur 
when least expected, and may lead to attacks on any 
person who happens to be present. Some insane patients 
are impulsively destructive to material objects only, 
such as glass or furniture, and are quite harmless in 
other ways ; while others will make assaults on persons 
as well, with or without intent to kill. These are the 
really dangerous lunatics, and even in them such out- 
bursts of passion can be avoided by proper care and 
treatment. Besides the automatic excitement of acute 
mania we have certain phases of mental depression 
(melancholia agitata, Chapter XIX) and delirium 
(Chapter IX), in which the patient also raves and de- 
stroys, but his activity is conditioned by painful states 
of feeling and frightful hallucinations, and is analogous 
to the acts of a sane person enduring torture. Impulsive 
acts of destruction occur also in imbecile persons (Chapter 
XXVI) and epileptics (Chapter XXV), and non- impulsive 
acts in general paralytics (Chapter XXII). 

* * * 

In order to maintain existence the animal must also 
avoid that which may compromise life ; it must be alive 
to the dangers which surround it. Animals having thus 
constantly to safeguard themselves against their numerous 
enemies to prevent themselves being destroyed have 
developed in addition a tendency to concealment which 
has also proved useful in approaching their own prey. 
This has given rise to the feeling of suspicion. Sus- 
picion is a protective instinct and hence a necessary 
mental quality. An animal cannot always protect itself 
by open force, and it must make up in cunning what 
it lacks in strength or courage. Among human beings 
this tendency has lost its significance, and shows itself 
more in the characteristic of reserve, and when deficient 



46 THE FIRST SIGNS OF INSANITY 

in openness. The truth is, that all men conceal much 
more than they declare, and an impulse to conceal is 
a constituent part of man, for the wise purpose of pre- 
venting that constant exposure of thought or purpose 
which would not only render society intolerable, but 
would remove a material guard against the evils which, 
by their selfish passions, men are inclined to inflict 
upon each other. 

In some forms of insanity the customary reticence is 
abandoned and the patient's first symptom of a morbid 
mental state is that he becomes expansive, and expatiates 
to strangers and persons of inferior station in life upon 
his private affairs and the misdeeds of members of his 
family. 

There are characters who are prone to suspicion, to 
mystery, and to duplicity, and who can never believe 
that honesty and fairness are anything else but baits 
laid out to trap the unwary. Such persons do every- 
thing in an underhand way, and as they imagine every 
one to act under the same motives as themselves, they 
are constantly on the watch to detect plots and devices 
which in reality do not exist. If adversity besets them 
for a time, their natural suspiciousness of character is 
exalted and sharpened to excessive activity ; they 
suspect everybody, they listen to every tale and gossip, 
and embitter their lives by suspicious fancies, till their 
best friends become as much the objects of suspicion 
as their enemies. Every trifling circumstance is then 
converted into a confirmation of their apprehensions, 
and the mind is kept constantly on the stretch to hide 
its own thoughts and to fathom the secret devices of 
others. They may start with a vague distrust, leading 
to the notion that others are more ready to do them harm 
than good, and this notion, by being indulged in, grows 
to a firm conviction that others are committed to an 
actual conspiracy to ruin or poison them or do them 
some other grievous injury. 

Delusions of persecution, so common amongst the 
insane, are due to suspicion. They are not perversions 
of the reasoning process, but arise out of the perverted 
emotional state. A suspicious person may reason quite 
correctly, but he will misinterpret actual occurrences 



DISORDERS OF THE ANIMAL PASSIONS 47 

because of the state of his feelings. When the disorder 
has lasted some time and the false ideas are habitually 
dwelt upon, they become realities to the consciousness 
of the individual. Such suspicious patients think that 
the people in the street look at them, they fancy that 
the newspapers write about them, that policemen or 
supposed enemies are following them, that there is a 
plot and a conspiracy to rob, ruin, and destroy them. 
Ill-founded suspicion of being despised or distrusted 
or a marked person is peculiar to paranoia (Chapter 
XXI) ; innocent looks or remarks are interpreted as 
having some deep meaning, and may lead to attacks on 
strangers. Melancholies (Chapter XIX) sometimes have 
delusions of persecution, attributing their misery to the 
influence of others, but they never react against their 
persecutors, but accept their supposed injuries as rightly 
deserved. Persecutory delusions, referring chiefly to 
mysterious objects and arising from hallucinations, are 
common to acute alcoholism (Chapter XXIII). Chronic 
alcoholics are very distrustful, especially as regards 
the fidelity of the wife or husband. In senile dementia 
(Chapter XXII) the delusions of suspicion and perse- 
cution are usually directed against the patient's own 
family, resulting sometimes in strange wills being made 
to the disadvantage of the wife, son, or daughter. On 
the other hand there is sometimes too much frankness 
by persons of disordered mind. Thus hypomaniacs 
(Chapter XVIII) are given to unburden their innermost 
thoughts to chance acquaintances, and so does the 
general paralytic (Chapter XXII) to undesirable com- 
panions. 

* # * 

The struggle of different species of animals for exis- 
tence has especially exposed the weak to continual risk. 
The consciousness of past dangers has rendered them 
cautious and caused them to fear their enemy. Hence 
has arisen the emotion of fear, which has as its object 
in nature to make the animal shrink from danger. This 
must happen automatically, otherwise it proves useless. 
There is often no time for reflection. Fear is the guardian 
instinct of life. Were there no emotion of fear experi- 
enced, we should not apprehend danger. Obviously the 



48 THE FIRST SIGNS OF INSANITY 

first necessity of man's continuance is his avoidance of 
physical dangers. He must be able so to adapt himself 
to the physical circumstances which surround him as to 
avoid placing himself in positions of peril. That the 
voice of a dangerous oppressor or the sight of danger 
should depress an animal's energies to fear, diminishing 
the vascular tone and producing a death-like appearance, 
must have been originally of huge preservative value in 
the struggle for existence. 

The tendency to fear and to employ the intellect to 
take precaution has been very unequally allotted to the 
different individuals of our species. Normally it pro- 
duces prudence and circumspection ; when deficient it 
causes recklessness and carelessness ; in excess it causes 
indecision, cowardice, and in some such a depression of 
spirits that under the slightest misfortune they fall into 
despair and think life no longer worth living. 

There is no emotion which gets so easily beyond con- 
trol as the emotion of fear, and none that has such far- 
reaching effects. The instinct of fear and its offspring — 
anxiety — weaken, dissociate, and paralyse the functions 
of the body and mind. When the instinct of fear is at 
its height it sweeps before it all other instincts. Nothing 
can withstand a panic. The fear of coming evil, especi- 
ally the unknown and mysterious, gives rise to the feel- 
ing of anxiety. If we expect to suffer, we are anxious. 
The anxious condition of mind is a sort of diffused 
terror. Fear and anxiety will interfere with the action 
of the other mental powers, so that a person finds no 
longer satisfaction in his usual pursuits and occupation. 
He becomes restless, sleepless at night, or has his sleep 
disturbed by disquieting dreams. The activity of all 
the bodily functions is diminished, hence there is loss of 
appetite, if not actual indigestion. 

Fear and anxiety are common symptoms in purely 
nervous as well as mental disorders. There may be an 
indefinite feeling of anxiety not awakened by any par- 
ticular cause, or it may be definite concepts and external 
influences which call the fear into action. 

Some persons suffer not from general fear, which 
would render them melancholic, but from special fears, 
so-called obsessions. They think themselves unable to 



DISORDERS OF THE ANIMAL PASSIONS 49 

execute certain acts on account of a supposed danger 
connected with them. The helpless situation makes their 
condition worse. The fear of public places, of enclosed 
places, the fear of fire in theatres, are all states of fear 
combined with nervous prostration. The patients rarely 
need telling that their fears are groundless ; much of 
their distress arises from their being unable to control 
fears that they realise are " foolish.'' (See " Neuras- 
thenia," Chapter XVI.) 

Some patients feel a lack of security and a lack of 
confidence in their own ability. They await with appre- 
hension the outcome of every act, and doubt its justi- 
fication and fitness. There develop a self-torture and 
an exaggerated feeling of liability. This type of feeling 
furnishes the basis for morbid fears. Unreasonable ex- 
cessive apprehension, vague feelings of anxiety, dispro- 
portionate grief and depression, with the attention riveted 
to the painful feeling, such are the symptoms common 
to melancholia (Chapter XIX). Terrifying hallucina- 
tions occur in alcoholic insanity (Chapter XXIII). 
Morbid anxiety as to health, that is apprehension of 
disease, is the main condition of hypochondriasis (Chap- 
ter XVI). Hypochondriasis is common to otherwise 
sane people, as, for instance, neurasthenics and hysterical 
people, as well as the insane. But whereas the former 
look for sympathy, the latter do not. Moreover, the 
fears of the neurasthenic do not occupy his whole being 
and continue all day and night, as those of the insane do. 
In the insane, too, the assumed disease is usually not an 
ordinary one, but can be recognised as a delusion fairly 
easily. On the other hand, fear and its intellectual 
combinations, caution and prudence, are often diminished 
or lost in insanity and lead to rash actions, often to the 
ruin of the patient and his family. 

3J» S|S 9|C 

Some animals have found it useful not to have to hunt 
continually for food which may prove scarce at certain 
periods, and hence began to store up things for future 
use. Thus has developed the hoarding instinct, a ten- 
dency to lay up provisions for the future. 

Man not only stores up provisions for winter, but he 

4 



for Fee 

50 THE FIRST SIGNS OF INSANITY 

acquires property of every sort and kind for all his life 
and for his posterity. This is a tendency which varies 
in different people ; the ability to do so depends on the 
intellect and other requisite qualities. It imparts the 
love of possession. 

With most men the hoarding instinct is the most pre- 
valent, and according to the development of the intel- 
lect and of moral sense it assumes a manner more refined. 
In the crudest aspect it can be noticed in idiots and im- 
beciles. They steal without reflection, merely to satisfy 
their animal instinct. 

Some men are grasping, avaricious. The pleasure of 
avarice consists in accumulating and hoarding up trea- 
sures ; in computing and gloating over them ; in a feeling 
of the power which they bestow ; and likewise in the 
consciousness of the possession of the means, though 
there be no disposition to employ them for the purpose 
of enjoyment ; and finally, it may be supposed, in the 
anticipation of future gratification they are to purchase, 
since even in the most inveterate miser there is probably 
a sort of vague looking forward to the time when his 
superfluous store will be brought into use to administer, 
in some way, to the indulgence of his desires and the 
consequent promotion of his happiness, although such 
a period never arrives. 

The painful feelings mingling in avarice are gloomy 
apprehensions for the safety of its treasures, with uneasy 
forebodings of exaggerated ills which would result from 
their privation. Hence fear, suspicion, and anxiety 
serve to counterbalance the pleasure arising from the 
contemplation and consciousness of possession of the 
soul's idol. 

The administration of the means may be perverted, so 
that expenditure is grossly inadequate. Economy may 
be pushed to such a degree of miserliness as in itself to 
constitute insanity. There is unhappiness accompanying 
every little expenditure, even for the common wants of 
life, the misery at times amounting almost to agony 
of parting with even the smallest fraction of that wealth 
on which the affections are so strongly fixed. A penny 
goes from the hands of a miser almost as though it were 
a piece of his own flesh. 



DISORDERS OF THE ANIMAL PASSIONS 51 

Among the perverted manifestations of this instinct in 
insanity we have, on the one hand, the patient who 
fears loss of property and destitution or thinks he is 
already ruined ; on the other, the parsimonious man 
who suddenly launches out into endless extravagance, 
giving orders for motor cars, jewellery, and other luxur- 
ies which he has often not the means to pay for, or else 
he makes imprudent investments or is given to im- 
practical business ventures. 

Another perverted activity of this instinct is klepto- 
mania. The origin of kleptomania can be traced to 
the infant, who will appropriate what does not belong 
to him ; the fascination of any new object, especially 
a glittering one, may prove too strong. He experiences 
a pleasurable feeling in touching things. Gradually 
the infant develops ideas of property, what is his and 
somebody else's, and learns to suppress the primitive 
propensity. 

Sometimes the older child still persists in appropriating 
things, now no longer from the pleasurable sensation 
of handling them, but from the enjoyment which the 
articles taken bring to him. He no longer takes a penny 
for the pleasure the handling of a bronze coin gives to 
him, but because of the anticipated enjoyment of the 
sweets he can buy with it. With judicious care and 
timely punishment the failing may be eradicated. With 
the development of moral sense the propensity will 
change its character and inspire the honest acquisition 
of property by proper work, and the original impulse 
will be suppressed. Occasionally at puberty it re- 
asserts itself, but even then, if no other signs of deficiency, 
such as lying, are evident, the moral defect may be 
purely transitory. 

Kleptomaniacs we call those persons in whom there 
is a strong desire to take possession of things quite irre- 
spective of their value, and disregarding risks of detection 
and the consequences of exposure, accompanied by a 
feeling of restlessness and anxiety when the impulse 
arises and a pleasurable feeling of relief and satisfaction 
on the execution of it. As in the child, it is the ap- 
propriation which gives the satisfaction, and not the 
enjoyment of the article taken, so that the objects 



52 THE FIRST SIGNS OF INSANITY 

appropriated are usually quite insignificant considering 
the position and wealth of the patient. In consequence 
the goods stolen are either thrown away or hidden or 
they are forgotten. 

There may be a difficulty in distinguishing a klepto- 
maniac from a thief when he happens to have the moral 
qualities insufficiently developed from brain defect or 
neglect of education, so that he lacks the inhibitory 
power to check his impulses. He steals then not so much 
from the satisfaction stealing gives him, but from the 
ideas of enjoyment of the stolen goods which prevail in 
his consciousness. That he is not a thief, in the ordinary 
sense, is manifest, inasmuch as he will steal still from 
the mere satisfaction stealing gives him, as shown by 
his sometimes appropriating articles of no, or incon- 
siderable, value to him, and without any precaution as 
to detection. Naturally the law can make no distinction, 
and punishment must be inflicted to provide a motive 
for the inhibition of an overactive propensity. 

In thieves, more especially in habitual thieves, we have 
the same acquisitive propensity which we have observed 
in the animal and child developed to excess in men in 
whom the idea of having to " work " for a living is most 
distasteful. They find " thieving " a more satisfactory 
means of livelihood. In some men in whom there is 
distaste for work there is no excessive acquisitive pro- 
pensity, but in its place a propensity to " wander/' 
regardless of its uncomfortable consequences ; these 
form our .tramps and vagabonds. Again there may be 
a distaste for work combined with special qualities of 
exciting the pity of their fellow-men ; such develop into 
professional beggars. 

The morbid impulse to thieving which we have 
observed in the genuine kleptomaniac occurs in various 
conditions of the brain when consciousness has become 
clouded to a more or less extent, as occurs for instance 
in some women during pregnancy (Chapter XXIV), or 
for example in alcoholic intoxication (Chapter XXIII), 
or sometimes in consequence of a head injury (Chapter 
XIII) ; lastly, in the still more clouded consciousness 
of hysteria (Chapter XVII) and especially in epilepsy 
(Chapter XXV). 



DISORDERS OF THE ANIMAL PASSIONS 53 

Pregnant women (Chapter XXIV) in the more ad- 
vanced state experience longings for various things, 
chiefly for unusual articles of diet however. If the 
longing extends to articles of dress or jewels and becomes 
irresistible in a woman, the fact of her pregnancy should 
be regarded as a secondary consideration, and her general 
mental state should be examined. 

The acquisitive impulse, in its most primitive form, 
is shown again in mental disorders, such as mania 
(Chapter XVIII), general paralysis (Chapter XXII), and 
senile dementia (Chapter XXII). It appears as hoarding 
instinct pure and simple, such patients filling their 
pockets or any available receptacle with anything they 
can lay their hands on, regardless of value, even with 
mere dirt. 

Petty thieving is by no means infrequent in weak- 
minded individuals (Chapter XXVI), who generally 
bear evident signs of physical degeneracy. It is especi- 
ally common in idiots and imbeciles. As a rule they steal 
without reflection, and merely to satisfy their animal 
instinct, although they display sometimes a considerable 
amount of ingenuity and low cunning. (See also " In- 
sanity and the Law," Chapter XXVII.) 



CHAPTER III 

DISORDERS OF THE SOCIAL AFFECTIONS 

We have been considering so far the dispositions im- 
planted by nature for the preservation of the individual, 
and shall now consider those instincts which are intended 
for the preservation of the species. 

The most primitive propensity for the continuation 
of the race is the sexual propensity, which like all pro- 
pensities may be either depressed or exalted in activity, 
or may be gratified in abnormal ways. In insanity it is 
often exalted to an extraordinary degree, leading to the 
most lascivious conduct. The speech is obscene, the 
gestures are suggestive of what is passing in the patient's 
mind, and indecent advances are shamelessly made to 
all of the opposite sex who come within reach (Nympho- 
mania in women and Satyriasis in men). The indulgence 
in the perversions of the instinct is considered by the 
law as a criminal offence, and since it is often only the 
forerunner of insanity and unaccompanied by any other 
symptom, the persons addicted to such practices are 
invariably convicted and sentenced as sane people. In 
most cases it is indeed a debatable question whether 
such people are insane, for their perversion may be 
merely an acquired habit ; but there can be no doubt 
whatever that all of them are degenerates, and signs of 
degeneracy are usually not wanting. 

In general paralysis (Chapter XXII) the symptom 
is often mistaken for the cause of the disease if a man 
of hitherto cleanly life chums with loose women or gives 
way to shameless indecencies in talk and behaviour. 
Exposure of the person is common in this disease as 
well as sexual assaults. It is not only men, but women 
also, especially during the climacterium (Chapter XXIV), 

54 



DISORDERS OF THE SOCIAL AFFECTIONS 55 

who, hitherto refined and modest, lose all regard for 
decorum and the amenities of society, and become 
negligent, coarse, and indelicate. They will dress up to 
attract men and run after them, and many a middle- 
aged woman has lost her character during her " dangerous 
age/' Overexcitation of the sexual instinct is also 
common to hypomania (Chapter XVIII) ; men paying 
marked attentions to women, making hasty promises 
of marriage, questionable allusions in conversation, or 
giving way to excesses and indecencies ; women showing 
increased inclination to self-adornment, seeking male 
society, flirting, talking of scandal, and inventing love- 
intrigues. Erotic tendencies are often revived in old 
men in senile dementia (Chapter XXII), which makes 
them easy victims to designing women and often causes 
them to be so misguided as to fall in love with very 
young girls. Sexual " delusions " are frequent in in- 
sanity, especially in those patients addicted to unnatural 
habits. 

From this instinct arises also the morbid desire to- 
wards some particular person of the opposite sex which 
people sometimes manifest without any sensual passion. 
Since the affection is rarely reciprocated, the person 
pursued has to suffer from unpleasant annoyances, which 
frequently lead to scenes, and not uncommonly end in 
the police court. The promise of good behaviour for 
the future is broken so often, that at last an inquiry 
into the state of mind of the morbid lover is inevitable. 

Hysterical women (Chapter XVII) seek romance in 
their love affairs, and if they are not sought after they 
sometimes interfere with the love affairs of others. 
Sometimes they are given to imaginary love affairs, as is 
also the paranoiac. In paranoia (Chapter XXI) the 
patient usually loves a person above his own social 
standing, generally secretly and mysteriously, and the 
affection is purely platonic. 

* * * 

Closely allied to the sexual instinct is parental love, 
the attachment of the parent to the offspring. This 
instinct is inherent alike in animal and in human nature, 



56 THE FIRST SIGNS OF INSANITY 

and is one of the instincts necessary for the protection of 
the race/for from their helplessness the young have to 
be safeguarded for a time. 

Disorder of parental conduct is not infrequent. The 
occasional desertions of infants and young children are 
instances of defect in maternal conduct, defects which are 
sometimes exhibited by parents in higher social strata. 
Excess of parental solicitude, to the extent that the 
health of the parent is damaged, and even the life sacrificed 
by devotion to the offspring, is not very uncommon, 
but not necessarily abnormal. Nor can that diversion 
of the parental instinct which leads an elderly spinster 
to lavish attention upon a pug-dog, a cat, or a canary- 
bird, in the absence of any more appropriate object, be 
looked upon as abnormal. There are, however, per- 
versions of the parental instinct which evince manifest 
disorder. Chief of these is the rage of destruction 
directed against the new-born offspring, which is such a 
frequent and terrible feature in the insanity of child-bed 
(Chapter XXIV). 

* * * 

Out of this parental love in human beings developed 
the attachment of the offspring to the person who takes 
care of them, afterwards to their brothers and sisters and 
other companions, as well as the attachment to home, 
forming the foundation of social life. 

There is a great difference among individuals in regard 
to the strength of social attachment. Some men have 
many acquaintances but no friends ; while others remain 
attached to certain individuals during every change of 
circumstance, and do not readily enlarge the circle of 
their intimates. When this feeling is strong in a person, 
delight is felt in friendship and attachment, the idea 
of distant friendship often presents itself, and the glow of 
affection rushes into the mind with almost the warmth 
and vivacity of a passion. Those in whom the feeling is 
weak care little for friends ; out of sight, out of mind, 
is their practice. 

The gregarious instinct is deeply ingrained in human 
nature. Total isolation from human companionship 
cannot be endured for long without damage to the mental 



DISORDERS OF THE SOCIAL AFFECTIONS 57 

health, and partial isolation, such as is suffered by those 
whose companions are seldom available, or imperfectly 
congenial, is, after a long interval, also detrimental. The 
vice of selfishness is intimately associated with a con- 
genital or an acquired loss of the social instincts. The 
virtue of benevolence represents a transformation of this 
instinct. Citizenship and patriotism represent the social 
instincts expanded, idealised, and applied for the happi- 
ness and well-being of large communities of men and 
women. 

In certain forms of insanity the social feelings become 
perverted, persons forming attachments to undesirables 
and outcasts, as in hypomania (Chapter XVIII) and 
general paralysis (Chapter XXII) ; or they become 
almost extinguished, solitude being preferred to company, 
as in melancholia (Chapter XIX). Even the death of 
a dear one may leave the patient indifferent. In others 
again separation from friends and country is a prolific 
cause of morbidity, well known as homesickness. The 
melancholic shuns society from the pain social intercourse 
gives him. The paranoiac (Chapter XXI) shuns it 
from mere distrust. The patient suffering from de- 
mentia praecox (Chapter XXII) keeps away from 
relatives and associates, being too much engrossed with 
himself. At the beginning of mania (Chapter XVIII), 
the natural affection for relatives is often in abeyance, 
and as the disease progresses, so the dislike of friends 
and relations becomes pronounced and increases to actual 
hostility. 

The change in the affection of a patient for his or her 
own family is often one of the most noticeable changes 
in character in the early stage of insanity. A patient 
no longer cares for her husband or for her children, and 
this lack of affection may be painful to her, since she is 
still conscious of having been very fond of them up to 
the time of her illness. Some patients show excessive 
grief at the loss of friends, often the first sign of oncoming 
melancholia (Chapter XIX). Others betray their in- 
sanity by their indifference to the sorrows of their friends 
and remaining unconcerned at their death. Sometimes 
the mental disorder shows itself in patients loving without 
measure those whom they soon hate without reason. 



58 THE FIRST SIGNS OF INSANITY 

Long-continued mental disease is especially distin- 
guished by an unsociableness which often prevents 
patients from speaking to their companions. It is no 
pleasure to them to be associated with their fellow- 
creatures. Many of them do not play games, and they 
cannot combine for any purpose. 

* * * 

From the social attachment there arose the desire to 
please, to earn the approval of those who are dear to us, 
and with whom we live in companionship. A man must 
so order his conduct as to gain the approval and good 
opinion of those with whom he consorts, and the desire 
of gaming and retaining this good opinion is one of the 
strongest of the motives by which his conduct is prompted 
and regulated. 

Such is the origin of love of praise and dread of blame, 
which are necessary elements in social life; and give 
rise to the desire to excel, that is to ambition. Exhi- 
bitions of perverted and excessive vanity are common in 
certain forms of insanity. In others one of the first 
symptoms is a want of attention to these minor obser- 
vances in matters of politeness, of convention, of cere- 
mony, and of courtesy, 

* * * 

Not only is external criticism held in account, but by 
a process of introspection self-respect has originated, 
and estimation of self and of one's individual work. This 
Self-love, one of the principles of our actions, differently 
modified, is equally productive of pride and modesty. 

Self-esteem and love of praise are two distinct faculties, 
although often confused by people. Self-esteem is often 
exaggerated to excess when there is disorganisation of 
intellect, but it is often carried to the ridiculous in per- 
fectly sane individuals, sometimes with reference to 
personal attractiveness, sometimes in regard to intel- 
lectual capability. The " bore " has plenty of it. Some 
men are successful in life through sheer " cheek." 

Self-esteem and self-satisfaction are prominent in 
hypomaniacs (Chapter XVIII). They admit only their 
own point of view and their own plans. A silly self- 
satisfaction is noticeable in the alcoholic (Chapter XXIII). 



DISORDERS OF THE SOCIAL AFFECTIONS 59 

On the other hand self-esteem is diminished, and there 
is a feeling of unworthiness in melancholia (Chapter 
XIX). In general paralysis (Chapter XXII) the patient 
believes himself to be an exalted personage, but he 
changes his character almost daily, if not hourly, being 
one moment a great general, another a king or statesman, 
a third a millionaire or a strong man, giving ample evi- 
dence of the weakening of his intellect. In the later 
stages of paranoia (Chapter XXI) the patient also be- 
lieves himself an exalted personage, often an underrated 
genius, but the character he fancies himself to be is 
fixed. He knows he is an important person ; he can 
tell you good reasons why. His intellect is perfectly 
retained, although he reasons from false premises. 

Generally speaking, amongst the insane we meet with 
men immensely overestimating their own importance 
and the significance of all their actions, engrossed only 
with themselves, and but little or not at all with external 
things. In early life there may be perhaps nothing more 
than a lack of self-confidence. Sooner or later the 
patient becomes hypersensitive, and gradually surrenders 
control of his thoughts at will ; instead of choosing a 
line of thought and concentrating upon it, he is dominated 
by some personal matter, broods over some real or 
fancied trouble, allowing it to engross attention to the 
exclusion of all other matters of interest. The habit of 
indulging in introspection grows upon him, and from 
being a useful and wholesome practice in the main, as 
exercised by a healthy, well-balanced mind, it becomes a 
source of danger when it defies control, and then perverts, 
hampers, and circumscribes mental action. 

Some people are so sensitive to criticism that they 
anticipate it keenly ; they become morbidly shy and 
shun society. They are too self-conscious. Of course, 
the emotion of fear is mixed up with it. But it is not 
merely fear of adverse criticism ; they are also shy of 
praise, and begin to blush all over. It is not always a 
sense of their own inferiority, for people who are con- 
vinced of their own capacities and themselves in other 
ways, as in their writings, yet evince that shyness before 
strangers. 

Shyness is natural at puberty. In women one takes 



60 THE FIRST SIGNS OF INSANITY 

it perhaps as more or less natural. Men afflicted with 
this complaint feel it more keenly, and therefore more 
readily consult the physician. They feel it when in 
company as if they were always observed and are doubtful 
that the observation may not always be sympathetic, 
or else they are eager to make a good impression and 
consequently become nervous. A shy person may blush, 
get confused, have tremors, show restless movements, 
have a nervous laugh, and a foolish expression with the 
eyes glancing restlessly in all directions. He sometimes 
tries to hide his discomfort. In consequence of these 
feelings he isolates himself from society and even 
ordinary companions sometimes, and becomes a lonely 
man, with all the evils of self-contemplation, self -intro- 
spection, eccentricity, etc., that are apt to develop in 
the recluse. Often it is the precursor of melancholia 
(Chapter XIX). 

From the egotistic feeling and that of vanity arises 
the feeling of jealousy. Some people are jealous through- 
out life ; their intense egotism brings this about at an 
early age, and even as boys and girls they suffer torments 
of their own creation. They conceive a violent affection 
for one or other of their comrades, which affection may 
not be returned with equal ardour, and so endless quarrels 
arise if the beloved one forms a friendship with any 
other boy or girl. In some this jealousy with regard to 
members of the same sex continues through life, there 
being no feeling of the kind for the other sex ; but in the 
majority of cases it is connected with the sexual feelings, 
and instead of the loves of boys for boys, and girls for 
girls, we find insane jealousy of husbands and wives, 
and an equal jealousy also in the unmarried or widows 
who are keenly anxious to enter the matrimonial state. 
The irrational display of this feeling leads to suspicion, 
searches, and doubts, and is sometimes carried to such an 
extent that a man's or a woman's life is made intolerable. 

Irrational jealousy, as distinguished from that on 
reasonable grounds by sane people, is often a symptom 
of insanity. Thus a chronic alcoholic (Chapter XXIII) 
may suspect his wife of infidelity, and from a morbid 
suspiciousness will find evidence in trivial circumstances. 
Again, women suffering from the mental disorders 



DISORDERS OF THE SOCIAL AFFECTIONS 61 

sometimes accompanying pregnancy or later in the cli- 
macterium (Chapter XXIV) become suspicious of their 
husbands, and are on the look-out for evidence, when 
trifles light as air will satisfy them of his guilt. They 
believe themselves neglected, search the husband's 
pockets, examine his blotting-pad, open his letters, and 
do other mean things to satisfy their unreasonable sus- 
picion. Sometimes they accuse their women friends of 
intrigue ; indeed, there is no knowing what a woman, 
suffering from an insane jealousy, may do. In the ex- 
treme there is danger of the jealous person, whether 
woman or man, becoming vindictive and inflicting an 
injury or causing even death. 



CHAPTER IV 

DISORDERS OF THE INTELLECT: 

PERCEPTION, MEMORY, REASON. 

HALLUCINATIONS, ILLUSIONS, DELUSIONS 

* * * 

I. DISORDERS OF PERCEPTION: 
HALLUCINATIONS AND ILLUSIONS 

Man possesses, in addition to the feelings he has in 
common with animals, intellectual powers of a superior 
order and higher sentiments which are peculiar to the 
human race. The intellectual powers are observation, 
memory, reason, and imagination. According to the 
degree of their development, so is the intellect of the 
individual petty or great. 

It is beyond dispute that the perceptive powers 
are the primary faculties of intelligence, and supply the 
raw material, as it were, for all intellectual exertion. 
Perception is a complex process. Our various repre- 
sentations, the different impressions made by the senses, 
would not exist for us without this element, which gives 
them unity and makes them an object of understanding. 
Perception is, then, sensation plus intellection ; the 
sensory ideas, whether visual, auditory, tactile, or other, 
on entering the domain of consciousness, are studied in 
all their relations to self and the external world. 

The commonest form of sense deceptions are hallu- 
cinations and illusions. The essential difference between 
the two is that the hallucination is purely a brain-crea- 
tion without any external stimulus to produce it, whereas 
an illusion is aroused by some real object outside the 
brain, and is, in fact, a misinterpreted sensation. Sense 
deceptions may occur in the sane. Their importance 

62 



DISORDERS OF THE INTELLECT 63 

in insanity rests on the fact that they exert a power- 
ful and irresistible influence over the entire thought and 
activity of the patient. 

Hallucinations depend upon disturbance of the 
centres of sensation, so that the person may hear, see, 
smell, taste, and feel things which have no external 
objects to evoke them, and yet so vivid is the impression 
made upon him, because of some abnormal excitation 
in his brain cells, that are ordinarily only excited by real 
objects, that he feels certain that the things heard, seen, 
etc., really exist in the world outside, though in truth 
they originate in his own brain. 

Besides the deception of the special senses, there may 
be hallucinations of general sensation and visceral 
feeling, as well as of the cutaneous surfaces. 

If the hallucination is recognised as such, it is a sane 
hallucination ; but in reality there is no such thing as 
a normal hallucination, although presumably normal 
individuals frequently experience them. Even in sane 
hallucinations there is, for the time at any rate, some 
disorder of the brain, some central disturbance in the 
brain mechanism. Even the presumably normal sub- 
jects of hallucinations, in the majority of cases, are 
mentally or physically exhausted, or are ill, or are in 
the half-dreamy state between sleeping and waking at 
the time of the appearance of the hallucination. Hallu- 
cination may then be defined as a morbid phenomenon, 
the result of dissociated cerebral action, by means of 
which a perception that has no objective basis or reality 
is subjectively perceived by the conscious mind and 
projected externally. 

If the hallucination cannot be recognised as such, it 
leads to a falsification of consciousness, and becomes an 
insane hallucination. In some instances patients can 
recognise them as at least very unusual, and so are 
often capable of concealing their existence for longer 
or shorter periods, as the case may be. 

Suspicion of insanity is always excited if hallucinations 
are present, but are not in themselves decisive as to 
the existence of insanity. They occur also in fevers 
and intoxications. The most that they prove is the 
existence of an abnormal cerebral condition. Hallucina- 



64 THE FIRST SIGNS OF INSANITY 

tions appear in their true light only when they stand 
in relation to other elementary disturbances, such as 
attacks of anxiety, etc., and when in the disturbed 
state of consciousness they are no longer corrected 
and influence the actions of the individual. 

Hallucinations of all the senses may occur at the 
same time, or there may be disturbances in only one or 
two fields. They may be agreeable, but more often 
they are disagreeable. Unpleasant hallucinations often 
give rise to dangerous conduct on the part of their victim. 

Hallucinations of taste are frequently found with de- 
lusions of poisoning. Delusions of the food being 
poisoned or unfit to eat occur for instance in melan- 
cholia (Chapter XIX), hence such patients may refuse 
to eat. 

When the sense of smell is affected, patients frequently 
complain of foul odours, of gases being forced into 
their sleeping apartments, and such complaints are 
not uncommon with certain forms of persecutory de- 
lusions, which are largely based upon them. 

Hallucinations of sight are particularly characteristic 
of toxic interference with cerebral action. They are 
common in all forms of alcoholism (Chapter XXIII), 
in poisoning by various mineral and vegetable drugs, 
in exhaustion, starvation, and long-continued thirst. 
Hallucinations of sight occur in acute mania (Chapter 
XVIII), horrible scenes are witnessed in the hallucina- 
tions of melancholies (Chapter XIX), repugnant objects 
in motion are seen in acute alcoholism (Chapter XXIII), 
fear-inspiring visions occur in inanition delirium (Chap- 
ter IX), and frightful hallucinations in puerperal mania 
(Chapter XXIV). Insane epileptics (Chapter XXV), 
too, are sometimes subject to terrifying hallucinations, 
and ecstatic visions are sometimes seen by hysterical 
women (Chapter XVII). 

The most common hallucinations are those of hearing. 
The patient hears voices, and generally words expressing 
definite ideas, though he is often unable to properly 
refer them to any speaking person. Sometimes, instead 
of external sounds or voices, the patient has a conscious- 
ness of an internal voice that may be as real to him as any 
external auditory perception. At first the voices may be 



i 



DISORDERS OF THE INTELLECT 65 

indistinct, but upon constant repetition and evolution 
from subconscious thought they acquire intensity, 
eventually dominating the life of the individual. They 
may at first be considered as the result of noises in the 
ears, and be corrected by the patient ; but after a time 
the iteration, together with brooding upon their derisive 
tone, conduce to a full belief in their reality. Their 
utterances may be agreeable, but it is more often the 
case that they are abusive, threatening, or command- 
ing, and annoying or absolutely distressing to the 
patient. The belief in their reality is so absolute that 
they are a positive source of danger, for one day the 
subjects may be able to control themselves and disregard 
the " voices " ; the next, they may feel bound to obey 
them and do what they command, whether it be homicide 
or suicide. 

Hearing voices is often the first sign of brain disturb- 
ance, and this state can remain stationary for years ; but 
for these voices such people may be in all respects sane, 
and conduct themselves as ordinary members of society, 
yet they are always to be looked upon with suspicion. 
Abusive and threatening voices are commonest in paranoia 
(Chapter XXI). They are constant, and follow the 
patient wherever he goes. 

Illusions are also deceptions of the senses, but they 
have an outside object as a starting point. An illusion 
is a false perception of a real impression. The object is 
not recognised in its real character, but is perceived as 
something else. The patient really hears, sees, tastes 
something, but thinks it is other than it is. He misin- 
terprets it. His sense impressions are as correct as ever, 
but the judging power is at fault. Some persons may 
experience illusions, but by bringing closer investigations 
and judgment to bear on them they are able to correct 
the false impressions. The sane man compares the 
visual object of delusion with the impressions of other 
senses and the perceptions of other persons; this is 
exactly what the madman cannot do. He concludes 
that what is only an illusion is a reality. But the illu- 
sion is not the madness. The madness lies in the want 
of power or resolution to examine. The insanity depends 
on whether the morbid sensation is meditated on and 



66 THE FIRST SIGNS OF INSANITY 

indulged in, and thus acquires fresh force, or whether by 
exciting other sensations it is weakened, and by degrees 
vanquished. 

The illusion like the hallucination may be of a pleasant 
or unpleasant character. Illusions of sight are the most 
common in the insane. Next to illusions of sight come, 
probably, those of hearing, and all the senses may be 
thus subject to misinterpretations in states of mental 
disease. A very striking class of illusions is that of the 
internal or visceral sensations ; a vague bodily sensation 
is attributed to some special cause — such as having a 
snake in the abdomen — altogether different from the 
reality. 

sfc * # 



II. DISORDERS OF IDEAS, MEMORY, AND REASON: 
CONFUSION AND DELUSION 

The powers of observation impart retentiveness and 
supply the essential material for practical knowledge. 

It is by means of the memory that we are able to 
recall former impressions and so form concepts upon 
three things : the vividness with which we are impressed 
with things presented to our minds, the power of retaining 
things presented, and the capacity to reproduce the 
impression. Without memory there would be neither 
past nor future. As there could be no recollection of 
the past, there could be no conception of a future, for 
this is the result of reflection, and without memory there 
could be no reflection nor any ideas to reflect upon. 

Anything which affects the normal reproduction of 
ideas affects the memory. The ideas may come so 
quickly into the mind that each one gets effaced because 
there are so many, or there may be conditions in which 
something interferes with the formation of memory 
pictures. In excited cases we see facilitated reproduction 
of ideas, so that things previously experienced and things 
experienced at the present time crowd so close that a 
jumble of ideas is the result. 

When the accuracy of memory is disturbed, we see 
the patient unconsciously distorting facts when telling 
them, or he may fix real experiences and imagined 



DISORDERS OF THE INTELLECT 67 

experiences together without knowing it, or may deal in 
fabrications which are really hallucinations of memory — 
the patient weaving an account of things often improbable 
and contradictory, that never existed, yet doing this all 
unconscious of the untruth. 

Defects of memory increase as age advances, and are 
most marked in elderly people. Defect of memory is, 
of course, a matter of degree. No one remembers all 
his experiences, and to forget is as natural and as normal 
as to remember, nor can any clear line be drawn between 
a defect that is within the normal and one that is 
beyond this bound. In practice, however, little difficulty 
is experienced in deciding that a defect of memory is 
morbid in degree, since by common consent no defect is 
considered morbid that is not extreme. 

Loss of memory is often very marked in insanity. 
The power of recollection — especially of recent events — 
disappears or is considerably diminished in general 
paralysis and in senile dementia (Chapter XXII). At 
the commencement of the former disease there is forget- 
fulness of ordinary duties and of details of business. 
Sometimes the recollection of former years is present, 
but no recollection of what has happened half an hour 
ago. Sometimes, also, there are delusions of recollection 
on account of the memory picture being insufficiently 
fixed. Or events that never happened are remembered 
as realities. On the other hand a very profound degree 
of apparent dementia is not inconsistent with an almost 
perfect recollection of events. The memory is impaired 
in chronic opium poisoning, and more so in chronic 
alcoholism (Chapter XXIII), where there is instantaneous 
forgetfulness of events which have only just transpired. 
On the other hand, in hypomania (Chapter XVIII) the 
memory is stimulated, so that the patient may be able 
to recall whole pages of poetry or to quote extensively 
from standard works. 

One important factor in order to remember is to 
exercise attention. There can be no accurate perception, 
and therefore no memory without this power of attention. 

The power of attention of a sane man has to be con- 
siderable, so that he may hold his ideas in the right 
order for a long time without fatigue. In idiots, on 



6& THE FIRST SIGNS OF INSANITY 

the other hand, it is occasionally so completely wanting 
that they cannot swerve the slow current of their ideas. 
Between these two extremes every possible grade of 
this power is met with. 

Absence of mind is common to sane persons, but more 
so to insane. Reverie and day dreaming should be 
discouraged amongst neurotic subjects. An excess of 
it is often an early sign of insanity, and so also must 
persons holding loud conversations with themselves 
arouse suspicion. 

Attention is variously affected in the different forms 
and degrees of insanity. There may be mere blunting 
and retardation of the attention and there may be 
suppression of the attention. The latter state occurs in 
stuporous patients where even shaking them will not 
rouse them, although they remember afterwards what 
has been going on around them. 



The power of reasoning upon the knowledge gained, 
of tracing the relations of cause and effect, and of deter- 
mining the analogies which obtain among things essen- 
tially dissimilar, comprise the next development. 

Most of the insane do not so much appear to have lost 
the faculty of reasoning as to have formed together some 
ideas, very wrongly ; they mistake these for truths, and 
they err as men do who argue wrong for right principles. 

When insanity affects the intellectual sphere, there 
may be abnormally slow thought or abnormally rapid 
thought, giving rise in the one case to dearth of ideas 
and expression, with a depressed emotional state as in 
melancholia (Chapter XIX), and in the other case a 
rapid flow of ideas, as in mania (Chapter XVIII), and a 
more and more jumbled way of expressing them as the 
disorder progresses, this latter condition being accom- 
panied by an exalted emotional state. Sluggish thought 
and slow halting speech, or no speech at all, is opposed, 
in the one condition, to rapidity of thought and speech, 
the flow of words increasing to a disconnected flight 
of ideas, till finally the association between the ideas 
can no longer be traced by the bystander. Such a stream 
of thought is called incoherent. 



DISORDERS OF THE INTELLECT 69 

Increase in the rapidity of thought is common to all 
states of mental exaltation, and the degree of rapidity 
of ideation is a valuable measure of the intensity of the 
cerebral excitement. The rapidity of thought may 
increase to such an extent that the patient loses the 
thread of conversation, he is no longer able to arrange 
logically the abundance of material that comes to him, 
and expresses senseless ideas, disconnected sentences, 
words, and syllables. In this condition logical thought 
has necessarily come to an end, and, since the flash-like 
ideas can no longer be co-ordinated or placed in logical 
sequence, the result is incoherence. Incoherence of 
thought and speech is, however, not exclusively the 
result of increase in the rapidity of thought or a symptom 
only of maniacal states ; it occurs also in various other 
abnormal conditions. 

Whilst rapidity of ideation leads to verbosity, slowing 
of ideation induces taciturnity. The person speaks only 
after long pauses and much hesitation, in a subdued 
voice, and only in response to very strong stimulation 
or to categorical and persistent questions. (See Dis- 
orders of Speech, Chapter V.) 

In hypomania (Chapter XVIII) the acceleration of 
ideas is at all events at first so slight that the patient 
may give the impression of being an entertaining con- 
versationalist, full of esprit, wit, and humour. It is in 
mania proper and in acute alcoholism (Chapter XXIII) 
that the ideas get confused, and often there is a repetition 
of ideas. The intellect is restricted in epileptic insanity 
(Chapter XXV), there is mental enfeeblement in chronic 
alcoholism (Chapter XXIII), and progressive mental 
weakness in a formerly clever youth occurs in dementia 
praecox (Chapter XXII). In melancholia (Chapter XIX) 
the intellect also remains clear, its processes are only 
retarded, because thinking becomes painful, so that the 
ideas do not flow, the response to questions is slow, and 
patients are incapable of long sustained mental effort. 
The most marked derangement of ideas is of course in 
dementia (Chapter XXII). 

A lack of ideas is characteristic of idiocy and im- 
becility from arrested brain development (Chapter XXVI), 
and, since the intellect acts as an inhibitory force and 



70 THE FIRST SIGNS OF INSANITY 

checks the animal passions, there is lack of self-restraint 
in the weak-minded. As regards his stock of ideas, the 
imbecile has been described as a pauper, the dement as 
a bankrupt. Their intellectual level is the same, but 
the one does not rise because he is unable to learn, the 
other falls because he has unlearned what he knew. The 
imbecile is and remains mentally a child, but the dement 
retains from his bankrupt stock remnants of developed 
intelligence. 

Thoughts are a man's constant companions. As an 
essential part of his being, and incorporated by his own 
act into his very self, they are always, and sometimes 
very obtrusively, occupying attention. They may be the 
means of minimising the ills and multiplying the blessings 
of life according as they are employed wisely or are 
allowed to brood miserably. In the sane person thoughts 
are guests entertained by choice and under control ; in 
the insane the thoughts, or some particular thoughts, are 
intruders who have been unwisely allowed to force an 
entrance into the sanctuary of the mind and cannot be 
got rid of. 

Some patients have ideas which irresistibly force them- 
selves into consciousness and are of an unpleasant and 
harassing nature. The patients are compelled to think 
constantly of some shocking experience or misfortune 
they have had or are anticipating. 

Obsessive ideas do not originate from the reason, they 
only interrupt it, and hence cause a conflict. The ideas 
are not willed, because they are recognised as fruitless 
and vain ; nevertheless they persist. They arise from 
the emotional state, and the intellect protests against 
them. Even normal persons sometimes are annoyed 
by some persistent idea, but, not paying serious attention 
to it, the idea vanishes. The person, however, who 
is suffering from brain-fatigue or nervous exhaustion 
(Chapter XVI) cannot shake off the morbid idea, because 
it represents some emotional state, generally fear. It is 
not that his intellect is perverted, but one of his feelings 
has become over-active. 

Behind the imperative idea there is to be discovered 
a phobia — that is to say, a special and original form of 
fear. There are very few timid normal persons who 



DISORDERS OF THE INTELLECT 71 

cannot boast of having at least a partial form of courage \ 
and there are very few brave persons who do not present 
at least one very limited form of pusillanimity. If the 
lack of harmony becomes a little exaggerated, it forms 
the obsessive atmosphere of a phobia, from which there 
arises the imperative idea or impulse. 

Fixed ideas are characterised by the obstinacy with 
which they remain in the field of consciousness, and by 
the manner in which they attract to themselves and hold 
fast the attention of the patient without there being 
any justifiable objective reason for their immobility. 
Moreover, this fixity is recognised by the patients them- 
selves as something clearly morbid, and they feel that it 
constitutes an obstacle to the normal course of ideas 
and actions, an extraneous element in the normal current 
of thought which no effort is able to dislodge. 

Fixed ideas may consist of words, numbers, phrases, 
or melodies, but they can also take the form of repre- 
sentations of useless, frivolous, or shameful acts, accom- 
panied by the tendency to execute them, e.g. obsessions 
of counting objects uselessly, of stepping in a certain 
way, of touching certain things in a regular order, of 
uttering obscene words, or injuring persons dear to one. 
Or the natural repugnance associated with certain acts 
is enormously exaggerated : thus there may be fear of 
contamination, of contagious diseases, of going into 
dangerous places. Or the fixed ideas consist in the 
representation of the impossibility of accomplishing 
certain acts, a representation which is translated into a 
real impossibility. Again, they consist in the represen- 
tation of involuntary phenomena, which, however, may 
actually take place through the simple suggestive effect 
of the representation as in the fear of blushing and in 
obsessive insomnia (Chapter XVI). 

In all these cases the constitution of the ideas is 
evidently unpleasant. When the idea is in itself of 
trifling importance, it is its fixity only which renders it 
unpleasant. Probably the idea which is presented in 
an unusually insistent manner does not assume the 
character of a fixed idea until its particular insistence 
has become an object of attention and a cause of un- 
easiness, and has been rendered not only harassing, but 



72 THE FIRST SIGNS OF INSANITY 

is also feared. The affective disturbance is the most con- 
stant element, and the one which explains how an idea 
is rendered stable which otherwise would be swept away 
very quickly by the ordinary current of association. 

Such imperative ideas, or obsessions, are thoughts 
which are fixed in consciousness with abnormal intensity 
and duration. Their content is as varied as that of 
delusions. They occur in neurasthenia (Chapter XVI) 
and hysteria (Chapter XVII) as well as in the course 
of mental disease, such as melancholia (Chapter XIX) 
and paranoia (Chapter XXI). 

Under all circumstances where such imperative thoughts 
and fears occur there is a state of irritable weakness in 
the central nervous system as one symptom of a tem- 
porary or lasting functional weakness of the brain. 

Some patients have persistent ideas unaccompanied 
by any feeling, and others " run to death the same 
ideas," as for instance in dementia praecox (Chapter 
XXII). Again, others have so little control over their 
ideas that in their speech they, so to say, " run off the 
line " by introducing a great multitude of non-essential 
accessory ideas, which both obscure and delay the train 
of thought. They are diverted by unimportant ideas, 
reminiscences, and incidents, and need to be frequently 
led back to their subject. 

Confusion of thought is extremely common, both in the 
sane and in the insane, and is an inseparable accompani- 
ment of delusion ; but it is often present also where 
there is no such definite belief as the term delusion can be 
applied to. By confusion of thought is usually meant a 
state of mind in which there appears to be a flow of 
disconnected and incongruous ideas, and in which the 
flow of language, at any rate, is disconnected and incon- 
gruous or, as it is usually called, incoherent. The patient 
may not himself be aware of anything unusual or abnormal 
in his mental condition, or he may feel and know that he 
is confused, and deplore his confusion. Whether recog- 
nised or not by the patient, it is always difficult to bring 
home to him the incorrectness, absurdity, and prepos- 
terous character of his thoughts, and this difficulty will 
be found to rest upon the existing confusion. 

Confusion is an important symptom in states of 



DISORDERS OF THE INTELLECT 73 

great exhaustion. In these cases it is to be attributed 
to a functional weakness in the logical combination and 
association of ideas as a result of which the threads of 
thought are continually broken, the train of thought 
rendered imperfect, and often totally unrelated ideas 
admitted into the mind. Of this nature, in such de- 
lirious states of weakness, is the constantly occurring in- 
terruption of the logical processes of thought by delusions, 
illusions, and hallucinatory perceptions, which in them- 
selves call up chains of ideas that are totally inharmoni- 
ous. (Hallucinatory confusional insanity, Chapter IX.) 
Patients vary, too, in the clearness of their conscious- 
ness. In many insane states the consciousness is clouded 
and renders the mental processes difficult. If recovery 
is sudden, as I have witnessed sometimes, the patient 
wakes up as if from a dream. In clouded consciousness 
there is often disorientation. Such lack of orientation — 
i.e. comprehension of the environment — may arise from 
disorder of memory, apprehension, or judgment, or these 

causes combined. 

* * * 

The power of deduction, finding out " the reason why," 
is an intellectual gift of humanity, which cannot be 
prized too highly. But like all other mental qualities, 
it too can be perverted. There are patients who for 
ever ask and try to answer questions to themselves, some 
of which are absurd, some metaphysical. It is with 
them as though the " why " of childhood were carried 
on to adolescence and maturity. Certain ones of this 
type will query, for example, " Why is the grass green ? " 
" Why did God create man ? " Some will debate with 
themselves as to whether, if they had pursued a certain 
course, the result would have been this way or that 
way. The broader the education, the more inclined are 
these persons to mental rumination on metaphysical 
questions. Others confine themselves to trivial subjects. 
If they are not interrogating themselves, they put 
questions perpetually to others. They must know the 
how, wherefore, and why of everything. Every answer 
they receive is met by further questions, so that they 
become a nuisance if not an embarrassment to everybody. 

When a person holds a belief that is demonstrably 



74 THE FIRST SIGNS OF INSANITY 

false — a belief that has arisen because of some dis- 
turbance in the perceptions and inability correctly 
to interpret them — and when he is unable to see the 
falsity of his judgment even when clearly pointed out 
to him, he is suffering from a delusion. It matters little 
what the patient believes, or how many false beliefs 
he holds ; the fact that he holds any one false belief, 
and holds it persistently and is unable to correct it, 
shows him to be insane, even though many of his 
mental faculties appear to be in their usual working 
order. People sound of mind may at times have delu- 
sions, but the essential difference between the erroneous 
conceptions of the insane and those of the sane lies 
in the fact that the former are not able to correct 
their sense errors, while the sane do so. In fact, a 
delusion is "a fixed belief in something that would 
be incredible to sane people of the same class, edu- 
cation, and race as the person who expresses it." 

Delusions are frequent, but by no means absolute, 
signs of insanity. It would be a great mistake to 
recognise insanity only when delusions can be demon- 
strated. In the early stage of insanity the delusion 
may not yet have developed, or the patient may suffer 
from a form of mental disorder, in which no delusions 
occur ; or he may suppress his delusions, or, even though 
present, they may not reach his consciousness. The sane 
may entertain the most outlandish false ideas, and even 
in this respect surpass the insane. On the other hand, 
the delusion of an insane person need not necessarily 
contain an objective impossibility ; indeed, the delusion 
itself may be objectively correct and at the same time 
have the value of a delusion. A delusion in an insane 
person is a symptom of a general abnormal condition and 
is related to other symptoms. The error of a sane 
person depends upon a defect of logical judgment or 
upon a false premise that has arisen out of uncertainty, 
carelessness, or embarrassment in the act of perception, 
such as superstition. A delusion of the insane is a 
symptom of brain disease, and therefore logic and reason- 
ing are powerless against it. The sane person will see 
his error and correct it as soon as it is shown to him to 
be absurd. 



DISORDERS OF THE INTELLECT 75 

The delusion of an insane person always has a sub- 
jective significance and an inner relation to his interests ; 
that of a sane person appears only as an objective error. 
Thus, both may believe in witches : the sane person, 
however, as a result of superstition and ignorance ; the 
insane person believes in them because he sees, feels, 
and believes himself threatened by them. 

Whereas the well-balanced person would check an 
erroneous flow of thought by sound mental orientation, 
the insane, instead of trying to check the mental error 
by seeking for the proper explanation of perplexing facts 
as soon as the delusional construction is under way, 
reaches out for every fact, recent or old, that falls within 
his knowledge, and contaminates it with a delusional 
and special significance to suit his primary conception. 

The cause that gives rise to delusions is an imper- 
fect adaptation of the individual to his surroundings. 
All delusions consist of fixed ideas, and vary only 
according to the individual culture of the patient ; 
otherwise they are always alike, or, at least, they 
follow their course of development in exactly the same 
manner in the same individual. 

Of course delusions are also caused artificially by means 
of various drugs, intoxicants, or toxines of organic or 
infectious nature. 

In infectious diseases or diseases due to auto-intoxi- 
cation (Chapter IX) the impure blood which circulates 
in the brain gives rise to a number of mental images and 
ideas which, while spurring on one another, are unsys- 
tematised. In the brain disease of the insane, on the 
contrary, although there, too, there may be infected 
blood circulating, the effect produced is totally different ; 
in this case the ideas are in unison with the fundamental 
tendencies of the individual, and they dominate him as 
long as they exist. In brain disorder or disease the 
ideas always have an intimate bearing on the person- 
ality itself. That personality may be depressed, exalted, 
or tortured by them, but they always bear the imprint 
of the personality, and this is explained by the fact 
that the cause which brings about the morbid changes 
does not come from outside, as is the case in fevers, 
intoxications, etc., but are the products of the brain itself. 



76 THE FIRST SIGNS OF INSANITY 

Both hallucinations and illusions, when believed in 
as real, give rise to false beliefs and delusions. The 
patient hears voices, yet he often fails to see any one 
to whom he can refer them. Accordingly he assumes 
in his mad way that the walls are hollow, that the voice 
comes through a telephone, or the like. Many patients 
hear voices insulting them, and are thereby led to form 
ideas of persecution. Or again, they have visual hallu- 
cinations. Forms appear and disappear in a very 
different way from the forms of external objects really 
present to their senses. Yet they cannot help regarding 
them as dependent on real external events. So they 
hit on a way out of the difficulty by, for example, sup- 
posing that some one is working mirrors and so conjuring 
forms up before them. 

Some delusions are simply the result of suggestion 
acting on exalted emotional conditions when judgment 
is in abeyance ; many originate in dreams or are con- 
ceived in the half sleep or the dreamy states of conscious- 
ness of many forms of insanity, and afterwards, by 
reason of constant brooding, become fixed and enduring ; 
or they may be developed as a result of external impres- 
sions, as when a paragraph in a book or newspaper is 
misconstrued, and by a process of false reasoning 
twisted to suit the insane purpose of the individual. 

In other cases they are simply the result of day- 
dreams of an ill-organised intellect. In still other cases 
they arise from excessive dwelling of the mind on single 
ideas and suspicions ; they take their start from an 
egotistic misinterpretation of facts, a sort of mental 
illusion. Whatever their origin, they are symptoms of 
defect of intellectual discrimination or judgment — that 
is, of a disordered intellect. 

The most frequent delusional ideas of the insane are 
personal humiliation and degradation, remorse, physical 
alteration of the personality, ideas of grandeur and mystic 
ideas. These delusions are generally fixed, and they 
invariably refer to the emotional side of the indi- 
vidual's personality, because they are entirely of sub- 
jective origin, and because their component ideas are 
not correctly regulated by conscious ideation of external 
origin, 



DISORDERS OF THE INTELLECT 77 

Sometimes the conduct of others, wrongly interpreted, 
is the starting-point for the wrong belief. Sometimes 
bodily sensations cause the patient to build false beliefs 
upon them. 

Sometimes the whole personality is in some way 
altered, but the patient is unable to describe the altera- 
tion which he feels ; sometimes the altered personality 
co-exists with the original personality, and the patient 
believes, in a confused way, that there are two beings 
within his body, or that he has another self somewhere 
outside of himself. Sometimes the personality is actually 
changed, and the patient has forgotten his past life and 
has changed to a man of totally different character. 
Another variety is the patient who believes that he is pos- 
sessed by a stranger or intruder, who thinks his thoughts, 
speaks, and acts for him ; or that he is possessed by an 
inanimate object. 

The delusions which refer to self and surrounding 
circumstances are either depressive, as in melancholia 
(Chapter XIX), or exalted, as in mania (Chapter XVIII) 
and general paralysis (Chapter XXII), later stages of 
paranoia (Chapter XXI) and dementia praecox (Chapter 
XXII), and may be accompanied by a feeling of misery 
as in the former or happiness as in the latter. Patients 
may suffer from delusions of unworthiness and incom- 
petence, self-accusatory delusions, delusions of sin and 
crime and vice on the one hand, and of impotence and 
inability and incapacity on the other. Persons affected 
with delusions of this class abandon themselves to 
despair as sinners of the unpardonable sin, or give 
themselves up to the police for crimes that they have 
not committed, or confess to faults and vices of which 
they are wholly innocent or which they greatly exag- 
gerate. They have brought themselves to ruin ; they 
have brought poverty and disgrace upon their families ; 
they have in some unexplainable way involved the 
whole village, the whole country, the whole human race, 
in ruin and disaster. There is no solace for them in 
this world and no hope in the next. (See Chapter XIX 
on Melancholia.) 

Or the patient may suffer from delusions of suspicion, 
persecution, and conspiracy. As he goes about the 



78 THE FIRST SIGNS OF INSANITY 

streets he thinks the people talk to each other about him, 
or look at him in a significant way ; their attitudes, their 
gestures, their very dress even, contain some occult quality 
which is intended to— and does — annoy and injure him. 
Sometimes it is a mysterious malign influence which is 
exercised over him. It may be by means of hypnotism, 
electricity, wireless telegraphy, or chemical vapours, as 
in paranoia (Chapter XXI). 

On the other hand, the false beliefs may take on an 
expansive character. The patient has delusions of 
exaggerated worthiness, competence or power, or the 
esteem in which he is held. The patient believes himself 
to be some exalted personage, or may think himself 
capable of great feats of bodily strength, of unprece- 
dented mental vigour, of untold wealth, or marvellous 
inventive, artistic, or executive ability. Such delusions 
occur in mania (Chapter XVIII), general paralysis 
(Chapter XXII), paranoia (Chapter XXI), and dementia 
praecox (Chapter XXII). 

As before stated, in the early stages a patient may 
suffer from insanity and yet have no delusions. He 
may be depressed, out of spirits — he cannot tell why. 
His business or even his amusements may be a nuisance 
to him. He may dislike seeing his friends, find even 
writing a letter a bore, and be irritable to those 
about him in a way he never was before. But as yet 
there are no distinct delusions. Conversely, a patient 
may display a state of exaltation and of change in 
this direction without delusion, as in hypomania 
(Chapter XVIII). He may talk in an excited and 
rapid way, much more than is his wont. He may be 
inclined to speculations, may build new houses or buy 
things he does not want, be disposed to quarrel, and 
by no means willing to take advice. He may sleep but 
a short time, rising very early and expecting others 
to do the same, and his whole conduct may be foolish, 
often causing his friends a fear that he has been giving 
way to drink. But all the time there may be no delusion. 
The fact that a patient has delusions is, as a rule, an 
indication that his mental disturbance has existed for a 
certain time and proceeded to a considerable depth. 



CHAPTER V 
DISORDERS OF THE HIGHER HUMAN CAPACITIES 

GENIUS, ECCENTRICITY, AND INSANITY 

One of the peculiarly human acquisitions is the faculty 
of speech. Speech becomes frequently affected in in- 
sanity, and the variety of its disturbance is a valuable 
aid to diagnosis. There may be increase in the rapidity 
of speech, from merely a rapid flow to actual incoherence, 
or the speech may be slow and stuttering ; or there may 
be mutism, there may be inability to say certain words, 
or to put the right word in the right place -; there may be 
silly affected speech, baby talk, senseless jargon, and 
gibberish, or wearisome repetition of a word or a phrase, 
or difficulty in pronouncing words; or there may be 
scanning speech. The unusual association of words, 
rhyming, and punning are also among the symptoms 
often noted. As a rule, the insidious approaches of mis- 
chief are generally foreshadowed by symptoms so trivial 
that they pass unobserved by patients and their friends. 
There may be a slowness and difficulty in expression 
and answering as in melancholia (Chapter XIX), in con- 
sequence of the painful effect any mental operation causes 
to the patient. The tendency to silence is often very 
strongly marked in acute melancholia, and may be 
interrupted only by cries and ejaculations of a painful 
nature. Disconnected sentences and meaningless phrases 
are repeated in inanition insanities (Chapter IX). Speech 
in monosyllables occurs sometimes in dementia praecox 
(Chapter XXII ). The speech may be slow in consequence 
of the feebleness of the mental processes, as in dementia 
(Chapter XXII). It may be voluntarily restrained in 
order to conceal secrets, as in paranoia (Chapter XXI), 

79 



80 THE FIRST SIGNS OF INSANITY 

or retarded in consequence of hypochondriacal ideas 
(Chapter XVI). 

There may be incessant talking, as in hypomania 
(Chapter XVIII), the patient allowing nobody else 
to speak. The speech may be flowing rapidly owing to 
the wealth of ideas, coming on so quickly that the 
sentences remain unfinished; but speech can be also 
flowing with a scarcity of ideas, as is peculiar to many 
sane people. 

The voice of the patient is almost always altered, 
becoming low and almost inaudible in melancholia, but 
high in pitch in mania. 

In connection with speech, it will be appropriate to 
consider here the handwriting of the insane. 

In general, it may be said that every principal form of 
mental disease has certain peculiarities of writing and 
expression, and that the patient in his writings, when he 
feels less under observation, gives freer expression to 
himself, and thus betrays more than in conversation. 
This is especially true of patients who obstinately refuse 
to talk because of delusions and imperative voices which 
command them to be silent. It is also often astonishing 
that patients who are quite rational in conversation, in 
their writings express the most irrational ideas. Writing 
that is rational does not exclude insanity any more than 
does rational speech. The writing of insane patients may 
reveal delusions otherwise concealed ; the style may 
enable a judgment of mental capabilities, and in its out- 
ward form permit a conclusion concerning the state of 
consciousness ; and the writing itself may be of impor- 
tance in determining the existence of the slighter dis- 
turbances of co-ordination. 

In many cases the writing of insane patients is de- 
cidedly incomprehensible, as the result of employing 
words in a new sense, transposition of syllables, the 
addition of senseless syllables, or substitution of hiero- 
glyphic and symbolic signs for letters. 

Words improperly written or the absence of words, the 
repetition of words or complete phrases several times, 
show disturbances of consciousness. 

In addition, while writing, the patient often forgets his 
real object, so that in the same letter he addresses himself 



THE HIGHER HUMAN CAPACITIES 81 

indifferently in several languages, delivers the letter 
unfinished, and forgets to put the address, the date, or 
the signature. Too, the outer appearances of a letter, 
the paper, perhaps found in the sweepings and covered 
with blots, indicates clearly the great disturbance of 
consciousness. 

Since writing gives greater clearness of thought than 
does speech, it is a very fine test of states of mental 
weakness. 

Imbeciles write the least (Chapter XXVI). The 
childish formation of sentences, awkwardness and lack of 
clearness in diction, indicate a high degree of mental 
weakness. Melancholic patients also write little (Chapter 
XIX). Here mental pain and inhibition are a hindrance. 
The monotony of thought reveals itself in the continuous 
repetition of the same complaints, fears, and self-accusa- 
tions. The writing does not flow in a stream ; it can be 
seen that the patient overcame his inhibition only spas- 
modically, and was able to express his thoughts only in 
fragments. Not infrequently the letters themselves are 
written with a trembling hand. 

The maniac (Chapter XVIII) writes much and rapidly, 
with a firm, steady hand, in large letters. It is thus a 
true picture of his accelerated thought, which oftentimes 
the hand is unable to keep up with, so that words are left 
out and sentences remain incomplete. If the flight of 
ideas becomes greatly intensified, then the handwriting 
degenerates into an undecipherable chaos of words and 
sentences that run into each other. In his impulse to 
write, the patient writes in all directions on the paper, 
and does not trouble himself about the material which 
he may have at hand. 

Paranoiacs (Chapter XXI), especially the querulous 
and erotic, are voluminous writers. Changes in their 
handwriting, consisting of curious eccentricities, curves, 
and the underlining of words and syllables are notice- 
able. The diction may be faultless, bombastic, or 
curious, in accordance with the nature of the delusions 
and the state of consciousness. The content of the 
writings of paranoiacs is of great value, since it often 
reveals delusions which are carefully concealed in con- 
versation. 



82 THE FIRST SIGNS OF INSANITY 

The writing of patients belonging to the paralytic 
group (Chapter XXII) presents special peculiarities. 
The disturbance of co-ordination finds its graphic ex- 
pression in handwriting that is indistinct or childish, 
zigzag or tremulous, and without distinction in shading. 

* * * 

Another highly developed human quality is the power 
of imagination, the creative faculty which enables us to 
visualise vivid mental pictures of the unseen and un- 
known, thus differing from memory, which only recalls 
the known and that which has impressed our senses. 

A marked feature of impending mental disease is seen 
in the tendency to allow the mind to wander away from 
the proper duties of life and luxuriate among scenes of 
the imagination or of ill-regulated fancy, so becoming 
dreamy and abstracted. Day-dreaming is done by the sane 
and overdone by the insane. In excess it is fraught with 
serious mischief to the mind. There is pleasure attached 
to its illusions, which renders it seductive and dangerous. 
Great activity of the imagination regularly accompanies 
an increased susceptibility of thought to external causes 
and susceptibility to auto-suggestion. Mental abstrac- 
tion occurs also in hysterical insanity (Chapter XVII), 
and day-dreaming and immature philosophising in de- 
mentia prsecox (Chapter XXII). 

* * * 

Men possessing imagination in a high degree sometimes 
tend to elevate and endow with super-excellence every 
idea conceived by the mind, and this stimulates the other 
powers to imagine scenes and objects, invested with the 
qualities it delights to contemplate. In this manner 
originated the aesthetic sense. 

Moreover, persons with a lively imagination are 
generally very susceptible to impressions, some only to 
the impression of objects, others to living things ; hence 
are they easily affected by the happiness and distress 
observed in others, and if their mental organisation 
supplies them not with counteracting motives, they may 
act up to the feelings produced in them, and exhibit 
kindness, charity, and generosity, thus leading on to the 
spread of happiness. This is the origin of the altruistic 



THE HIGHER HUMAN CAPACITIES 83 

sentiment. One of its elements, sympathy, is that 
susceptibility which renders one individual ready to 
catch the contagion of the emotion of another individual, 
leading men to grieve at the sorrows and rejoice in the 
pleasures of their fellow-men. 

In insanity men often become abnormally egotistic, 
or else there is apathy or indifference ; rarely the 
altruistic feeling predominates. 

As a rule, the higher mental faculties, those which are 
added latest in the scale of evolution, are the first to 
deteriorate, hence a change in the moral nature of man 
is often the first symptom of unsoundness of mind. 
Failure arid decay of the moral sense occur in several 
forms of insanity, for example in general paralysis 
(Chapter XXII). In chronic intoxication, as by alcohol 
or opium (Chapter XXIII), it takes the form of untruth- 
fulness, loss of sense of honour, and loss of regard for the 
feelings of others. There is, too, ethical insensibility in 
chronic dementia (Chapter XXII), and there are other 
forms of weak-mindedness, when people yield readily to 
temptations and cannot appreciate utilitarian considera- 
tions. 

Ethical sensibility is exaggerated in certain forms of 
insanity, conscientiousness becomes hyperactive, and 
patients accuse themselves of having neglected their duty, 
or they worry about supposed sins committed in their early 
youth, of which they had not thought until the commence- 
ment of their illness. When delusions are added to this 
state of mind, such patients make all sorts of self-accusa- 
tions. (See Melancholia, Chapter XIX.) 

Not infrequently the loss of altruistic sentiment forms 
the only residuum of an attack of insanity that has 
apparently ended in recovery. Such individuals return 
to their former life, and may even be capable of leading 
their usual social existence ; but, in contrast with their 
former selves, they have become Philistines and egotists. 
The welfare or suffering of their fellow-men no longer 
appeals to them. Even the old bonds of family and 
friendship are loosened and only maintained by habit, yet 
with this lack of interest in all the higher aesthetic and 
ethic relations of civilised life they still satisfy their 
material needs and perform their duties. 



84 THE FIRST SIGNS OF INSANITY 

Under this head may be included the phenomena of 
what is called moral insanity (Chapter XXVI), insanity 
of acts or conduct in which the patient seems, while 
reasoning correctly, to be incapable of so directing his 
behaviour as to make it consistent with what should be 
expected of him in his condition and circumstances of 
life. The patient shows aberrations in the moral or 
ethical side of his nature, or in the sense of propriety and 
decency. He may apparently lose all the check of con- 
science and deliberately violate moral law in every 
possible way. Most of these people have been peculiar 
from childhood, unable to learn like others, to go to school 
and to take their place by the side of others, and many of 
them are quite unable to distinguish right from wrong. 
So long as they remain children they may be taken care 
of by parents and guardians, but when they emerge from 
childhood, and have to assume the responsibilities of men 
and women, they come before us in various ways, and our 
opinion will be sought concerning their mental state. 

In humble life these defective boys and girls will very 
likely develop vicious propensities and swell the ranks 
of the criminal classes ; in a higher station of society 
they are the torment and difficulty of parents. They 
may display at an early age a tendency to immoral 
conduct of all kinds and a total disregard for truth ; 
they may steal in a way which they think clever, but is 
in reality silly ; consequently, no school or tutor will 
keep them. They may be told with the greatest care 
and in the most impressive manner that it is wrong to 
steal and wrong to lie. They will repeat what is said 
to them, and assure us that they know it is wrong ; but 
they learn it as a lesson, and it all goes out of their head 
like a lesson in Roman history or the Latin grammar ; 
the next day it is clean forgotten, and they go back to 
their abnormal and vicious habits quite unreformed. 



To these higher sentiments belong also the feelings of 
wonder and awe aroused by the sublime and vast in 
nature, the feeling of veneration and reverence awakened 
by the recognition of the exalted influence of authority, 
faith, and belief aroused by appearances for which the 



THE HIGHER HUMAN CAPACITIES 85 

intellect can find no natural causes, and the spiritual 
feeling arising from appearances which suggest another 
life existing besides that known to us. 

The human mind is prone, in the presence of the un- 
known, to seek short cuts. Surrounded by the elements 
and forces of nature which he could neither comprehend 
nor control, they became for prehistoric man awe-in- 
spiring mysteries, and when it was brought home to him 
that they were capable of doing him harm, even of 
taking his life, they became for uncritical man superior 
animate beings whom he endowed with qualities like 
his own, whose favour was to be courted and whose 
wrath appeased. 

In some men these, which may be termed religious 
feelings, are all-powerful. Such are given to contem- 
plating the spiritual state, and seldom turn their attention 
to gross matters and mere animal pleasures. Men in 
whom these feelings are lacking tend to be sceptical. 
They have faith only in their own experience, and think 
more of an animal existence than of spiritual life. 

However much the modern intellect trained in strictly 
scientific pursuits may try to curb the spiritual in- 
clinations, there can be no doubt that the religious senti- 
ment through long generations has become an element 
of our nature. Even the atheist, as a rule, experiences its 
emotions when circumstances arise which appeal to his 
feelings rather than to his intellect — that is, when he 
allows his nature free play. 

Genuine prayer, not the recitation of words learned 
and repeated parrot-like, is as good for the brain as 
exercise is for the muscles, and tends to keep the brain 
in health by preserving the proper balance between the 
altruistic and egoistic sentiments. I refer to prayers 
not for rain when it is dry, or for peace when there 
is war, but for patience under affliction, for charity, and 
for courage. Prayers for such subjective qualities may 
indeed be said to assure themselves being heard and 
answered, for by placing the mind in an attitude of 
patience or charity, as the case may be, they fit it for 
the habitual exercise of those functions. A critical 
analysis of our conduct, as in meditation, sets the intel- 
lectual and moral faculties in ascendance over- the 



86 THE FIRST SIGNS OF INSANITY 

animal propensities, and thus further strengthens the mind 
in the right direction. Even a prayer for health in a 
truly devout person may have a beneficial effect through 
the increase of nervous energy supplied to the ailing part, 
in the same manner as suggestion acts therapeutically 
in many functional diseases, and occasionally improves 
the condition of diseased organic parts. Prayers for the 
common good are also beneficial. 

Of course, patients who are already over-conscientious, 
introspective, and over-zealous in their religious duties 
should not be encouraged in these directions ; on the 
contrary their mind should be diverted into other and 
practical channels. 

When the religious sentiments are developed in excess, 
the person is inclined to mysticism ; and when perverted 
or not guided by the intellect, there may be superstition, 
bigotry, fanaticism, delusions, and a ready belief in 
ghosts, apparitions, magic and mysterious occurrences. 
The intellect being less highly developed, it is guided by 
the stronger impulse, and may even be employed to search 
for arguments to support the credulity. 

Defect of religious conduct is common enough without 

carrying with it any implication of insanity ; but excess 

and disorder are occasionally seen, and are more decidedly 

abnormal. In insanity we often find a devout person 

beginning to exhibit indifference to things sacred, becoming 

irreverent, profane, flippant. Others are possessed by 

religious doubts, while still others develop excessive 

religious devotion, as in epileptic insanity (Chapter XXV), 

or absurd ideas of a religious and occult nature, as in 

dementia praecox (Chapter XXII), or delusions of a 

religious character, as in paranoia (Chapter XXI) . 

* * * 

In connection with this description of the highest 
qualities of the intellect, a few remarks about the re- 
lationship between genius, eccentricity, and insanity will 
be appropriate. 

Amongst uncultured men and low, simple types of 
mind, insanity is comparatively rare, though idiocy and 
imbecility from arrest of brain development are common. 
At the other end of the scale we have the highest type 
of mind, that of genius. This type of mind is relatively 



THE HIGHER HUMAN CAPACITIES Sy 

complex, and complexity is liable to instability. A fine 
and complex machine is more apt to go out of order than 
a crude and simple one ; but complexity is not necessarily 
followed by disorder. 

The highest mind is the finer mind, hence some or all 
the mental powers are sharper, enabling the man of 
genius to form unusual associations of ideas and to see 
things in new relations ; but he not only sees things which 
the ordinary man cannot see, but he materialises his 
ideas — hence we get the world's best discoveries, inven- 
tions, literature, music, painting, and sculpture. 

The mental operations of a great genius are not like 
those of mankind in general, but the differences are 
within the normal range, and consist mainly in the fact 
that they are such as others are not accustomed to, 
merely because they are new. They are in advance of 
their time, and hence often induce the belief that their 
possessor is insane. 

Genius connotes an extraordinary gift for particular 
work, but also the power to persevere in the labour 
that is needed for its accomplishment. A man's genius 
shows him the value of patient labour, and aids him to 
persist in it. A genius may possess certain eccentricities, 
but has generally self-control which enables him to survive 
failure. Frequently it is adversity that spurs him on. If 
he is successful, it is not by "good luck/' it is not by 
any occult occurrences, but by opportunities promptly 
utilised, a characteristic which shows his sanity. We 
cannot all be geniuses. A real genius does not produce 
his work because it brings wealth, fame, or happiness, 
but because he has the impulse to produce, whatever 
its consequences. Sometimes he has been stoned for it. 

The insane person generally shows signs of mental 
derangement in more than one direction, and exhibits 
that inability to give long-sustained attention to any 
one subject/which is so marked a symptom of insanity. 
The genius is usually consistent in the one thing which 
makes him original, whether it be in the work which 
he does or which he proposed to do/ The imagination 
plays an important part in the mental operations both of 
the man of genius and of the lunatic ; but the one makes 
use of this faculty for the accomplishment of the objects 



88 THE FIRST SIGNS OF INSANITY 

he has in view, while the other becomes its slave and 
is led hither and thither by its vagaries. 

The existence of mental defects, obliquity of mental 
vision, imperfect cerebral development, and marked 
defection of character is scarcely compatible with the 
breadth of view, powerful imagination, and great in- 
tellectual strength of men in the very first rank of human 
genius. 

The genius is considered such when he develops ideas 
that are really of value. But there are many persons 
who have all his qualifications, except the one of being 
able to materialise their ideas. They lack the ability 
to do, as well as to contemplate. Such persons are prone 
to dream of revolutionising the race with their ideas, 
but it never comes to anything. They lack the practical 
execution, and their visions come to naught. In the 
pursuit of their extravagant plans they completely lose 
sight of the realities of life, keeping their gaze fixed only 
upon the results, while they never take into serious con- 
sideration the difficulties and insufficiencies of their 
methods. Yet they hold to their ideas, however unusual 
and absurd, till everything is coloured and distorted by 
them. 

It is in the use of faculties, not in the mere possession 
of them, that lies real greatness. Many men possess 
the necessary capabilities for distinction in a particular 
subject or pursuit, but they have not the will and wisdom 
to use them industriously. Industry, when well directed, 
would make many men great, but gifts so called rarely 
have conferred greatness upon any. Of such prolonged 
application and energy only a sane mind is capable. 
The insane often have lucky inspirations, but not the 
perseverance to carry a work to its completion. If they 
do finish their task, they are certain to spoil their work 
before the end has come by the introduction of some 
insane idea. I have seen paintings spoiled by the finish- 
ing touches of an insane artist, and I have read poems of 
magnificence and essays of splendid composition but for 
their last sentences. 

The liability of men of genius to insanity is partly due 
to their great sensibility, which implies a finer and more 
subtle delicacy of thought and feeling, which permits of 



THE HIGHER HUMAN CAPACITIES 89 

a keener sympathy and a deeper, clearer insight into 
men and things, than are granted to ordinary beings. 
That this constitutes a defect of often great consequence 
to the individual, as well as a quality of still greater 
import to the race, is sufficiently clear. Sensations and 
observations which the ordinary man hardly notices are 
transformed by gifted men into great creations ; at the 
same time disappointed hopes, failures, and adversity 
are felt more keenly by them. Men of genius are, even 
with apparent outward good fortune, men who most 
deeply and irremediably feel the wretchedness of existence. 

Persons whose minds deviate in some one or more 
notable respects from the ordinary standard, but yet 
whose mental processes are not directly at variance with 
that standard, are said to be eccentric. Eccentricity is 
generally inherent in the individual or is gradually 
developed in him from the operation of unrecognised 
causes as he advances in years. If an original condition, 
it is often the result of early training emphasised by a 
special environment. These individuals are often men- 
tally brilliant in some directions, but are handicapped by 
deficiency in those qualities which would aid them in the 
competition and struggle of existence. 

Eccentricity is not always an original condition, for, 
under certain circumstances it may be acquired. A 
person may meet with some circumstance in his life 
which tends to weaken his confidence in human nature, 
and he accordingly shuns mankind and becomes peculiar 
in his ways. Such a man is not insane. There is a 
rational motive for his conduct. 

Eccentricity and genius often co-exist in the same 
person, and this fact has served in the minds of some 
writers as a reason for regarding genius as a morbid mental 
manifestation. There is generally to be observed in men 
of genius a novel and bizarre way of regarding events, 
and unconventionalities of conduct which have the effect 
of estranging them from their fellows. No doubt this 
is partly due to the fact that the genius lives in the 
van of his age, that he therefore differs from it, and is 
in consequence pronounced mistaken, unpractical, or 
mad. Formerly, too, a disorderly life was indulged 
in especially by literary geniuses, which they fondly 



go THE FIRST SIGNS OF INSANITY 

believed was a help to inspiration ; but fortunately 
this is both unnecessary and impossible now, hence our 
literary men are saner. 

The real man of genius does not mean to be singular 
or original, but he is, nevertheless, both. He endeavours 
to carry out certain ideas which seem to him to have been 
overlooked by society, to its great disadvantage. Society 
usually thinks differently ; but, if the promulgator is 
endowed with sufficient force of character, it generally 
happens that eventually, either wholly or in part, his 
views prevail. All great reformers are eccentrics of 
this kind. They are contending for their doctrines, not 
for themselves. And they are not apt to become insane, 
although sometimes they do. 

While we have on the one hand the highest develop- 
ment of the intellect and human sentiments in the vanities 
of genius, we have on the other an arrest of development 
in the different degrees of idiocy and imbecility which 
will be described in Chapter XXVI. We must mention 
here also the general weakening of the entire mental 
powers, sometimes seen primarily in adolescence and in 
old age, beginning in an individual previously sane, but 
most often secondarily to attacks of acute insanity, a 
decay of the faculties of the mind as a consequence of 
some pre-existing form of insanity. We shall deal with 
these mental states in the chapter on Dementia (Chapter 
XXII). 



PART II 
THE CAUSES OF INSANITY 



CHAPTER VI 
HEREDITARY DISPOSITION TO INSANITY |I 

In order to prevent insanity, we must avoid the causes 
which give rise to it. It is our first duty, therefore, to 
study the various conditions which dispose towards the 
disease. 

The human race of to-day is the expressed sum of all 
the good, bad, and indifferent that have ever existed in 
the world, from the beginning. It depends greatly on a 
man's ancestors whether he is to be a fool, a genius, a 
madman, or a criminal ; whether he is to be a success 
or a failure in life. No fact is more certain than that 
a tendency exists for a child to exhibit the physical, 
psychical, and ethical tendencies of his forefathers. 

No one feels surprised that a child resembles one of its 
parents. Indeed, we are astonished if qualities, whether 
of mind or body, manifest themselves in a child which 
we have not known in his progenitors. If any trick or 
mannerism appears in a child, we cast back, even in- 
voluntarily, and search for it in his ancestors. Should 
any abnormality of body exist — a hare-lip, a club-foot, 
a tuft of differently coloured hair — we are satisfied at 
once if we know that some similar abnormality, some 
such malformation, has occurred in the family of the 
father or mother. 

We know that the brain controls the whole of the life 
processes of an organism, hence those acquired characters 
which do not affect the brain directly are not transmitted ; 
on the other hand, those which do affect the brain directly, 
either through voluntary or involuntary action, are 
transmitted. For instance, we may cut off the mouse's 
tail for generations, yet they will still be born with their 
tails. Such mutilations have no modifying influence on 

93 



94 THE CAUSES OF INSANITY 

the nervous system, and brain in particular, and therefore 
cannot be inherited. 

It is otherwise, however, when an acquired character 
directly affects the brain, that is, increases or lessens any 
of its functions in any way. Loss of a limb or any other 
portion of the body does not affect the brain, at least not 
to any appreciable extent. But if, through change of 
circumstances, new efforts for the preservation of exis- 
tence are called forth, such efforts must originate from 
the brain, and hence the brain is directly modified, and 
this change in structure may be transmitted. We thus 
learn that not all kinds of acquired characters are in- 
herited, but only those which produce a modifying effect 
on the governing portion of the nervous system, that is, 
the brain. 

If an animal through a change of circumstances has 
to make certain new efforts to obtain food, etc., these 
efforts must originate from the brain, since they are 
voluntary, hence the brain is directly modified, and the 
parts in connection therewith are also modified. And if 
the change in circumstances is permanent, inducing 
similar effects on the part of the off-spring, gradually 
the modifications thus produced are inherited, and in 
time, if the changes in structure are typical, change of 
species occurs. Again, if through a change of climate an 
organism is affected through the whole of its surface 
nerves, a direct impression is made on the brain, which 
impression leads in time to a permanent modification 
of character. Such a change of character and its in- 
heritance is seen in a change of complexion, as, for 
instance, where Europeans gradually acquire a darker 
skin, and also where wool gives place to hair in sheep, 
introduced from a cold or temperate climate to a tropical 
one. 

The face of the child resembles the parent where there 
is a marked " character." The character has its origin 
in the brain, hence the muscular expression continues 
to be transmitted. 

The elementary psychical powers which we have des- 
cribed in the previous chapters are innate, for they cannot 
exist without a brain, and they must be instinctive to 
preserve the individual and the species. Argument is 



HEREDITARY DISPOSITION TO INSANITY 95 

possible as to whether we have psychologically really 
arrived at the elements or whether we are still describing 
complex mental powers, but that is only for want of 
psychological knowledge and proper terminology. 
Thus, for example, it is said of musical ability that it can 
be inherited, and we are referred to the number of musical 
prodigies who surpass many an adult musician in technical 
ability and capacity for composition. Now, of music, 
we do know that it is a complex faculty, and that what 
is really inherited is a tendency to the appreciation of 
sound and harmony, but not the musical knowledge. 
Similarly, the artist inherits a tendency to the apprecia- 
tion of colour and beauty of form, but not artistic 
knowledge. That is why it is perfectly true that a 
genius implies a capacity for taking infinite pains. Only, 
the pains he takes are agreeable to the man of genius, 
for they are in a branch of art or knowledge which is 
natural to him, since he has an innate capacity for it. 

It is an incontrovertible fact that individuals experience 
great difficulty in acquiring some kinds of knowledge, 
while in other departments of learning they make 
rapid progress ; they feel instantly at home, and 
experience in such studies nothing but delight. A boy 
may have received a classical training, and may have 
shown the greatest aptitude in learning languages, and 
yet in the ordinary affairs of life and in other depart- 
ments of science he may display the greatest imbecility. 

Every one knows that the children of musicians may so 
vary as to be more or less musical than their parents 
and yet all be more musical than the average man. 
Suppose the most musical men marry musical women, we 
thus have generations following, some of whose members 
are increasingly musical by normal variation. This 
has happened in the family of the Bach's, and it is the 
same process as the development of the racehorse — a 
selecting of the best developed, and the intensification 
of the variation, and not transmission of acquired modi- 
fications. Only a small proportion of them vary so as 
to be more specialised than their parents, so that they 
are not all great musicians ; nor are all the racehorses 
great racers. Each child has to acquire its musical 
knowledge just as painfully as its parents, the only thing 



96 THE CAUSES OF INSANITY 

it inherits is the ability to do this. So the racehorse 
must be trained to run races ; the only thing it inherits 
is the capacity for being trained. No amount of training 
will make a horse a racer without this innate capacity ; 
nor can we make a singer or an artist without the innate 
capacity. 

It has been said that the exceptional talents and 
characteristics of some men are due to accidental causes, 
but the same opportunity is offered to a great many men, 
while only one is inspired. The fact is that education 
and surrounding circumstances are only powerful on 
those men whose innate dispositions are neither too feeble 
nor too energetic. A man of talent may have an im- 
becile for his child, but no man of talent ever had an 
idiot or an imbecile for his father or mother. All that 
external impressions or education can do is to give an 
impulse to those talents and characteristics which have 
not put themselves in activity before, but the disposition 
for such must exist previously. No child would ever 
talk unless he were taught ; and no child could be taught 
to talk unless he already possessed, by inheritance, a 
particular organisation ready for training. 

A man may indeed, within limits, mould himself, but 
the materials he can alone use were handed on to him 
by his parents, and whether he becomes a man of genius, 
a criminal, a drunkard, an epileptic, or an ordinarily 
healthy, well-conducted, and intelligent citizen must 
depend at least as much on his parents as on his own 
effort or lack of effort, since even the aptitude for effective 
effort is largely inborn. 

From these remarks it is evident that men do not start 
in life equally, but with advantages and disadvantages 
according to their inherited organisation. Even if all 
education, including that of the universities, were made 
free, there would always be some whose organisation, 
even after all educational efforts have been tried, would 
fit them only for the position of a shoeblack or a kitchen- 
maid. 

It is an antiquated and exploded theory held by our 
forefathers that all men are born equal, which is 
another way of saying that they all have the same 
natural abilities. The present generation knows better 



HEREDITARY DISPOSITION TO INSANITY 97 

than any past one that Nature, like the potter, makes 
her " failures," that she turns out her sound pots and 
her cracked pots, and though she works to a general 
pattern, she varies infinitely the details of each piece of 
work. 

There can be no such thing as social equality so long 
as men are born into the world with unequal mental 
gifts. The highly organised brain is born to lead, to 
dictate, and to govern, while the more weakly endowed 
is born to a life of servitude and submission. 

If the intellectual powers are naturally very weak, no 
education can render them strong ; and if they have been 
naturally very strong, they will remain so even without 
education. Education can improve the powers of man, 
but not to an indefinite extent. The man who has natur- 
ally a weak verbal memory may improve it by education, 
but never to the extent of an individual who has that power 
naturally strong. If the reflective powers of an individual 
are naturally weak, no system of training can render 
that individual pre-eminent in metaphysical or abstract 
speculation. By education his powers will be improved, 
but in no circumstances could he be made to equal a 
Locke, a Newton, or a Bacon. 

The different schools of heredity — Darwinian, Weiss- 
mannian, Mendelian, and Galtonian — would have far 
less scope for dispute if they first agreed what characters 
are really elementary and instinctive and therefore 
likely to be hereditary. There is really not so much 
difference as is apparent. Thus, an eminent Darwinian 
deplores the fact that " there is no more pathetic figure 
in human experience than to see descend into the grave, 
to pass away for ever, all those endowments with which 
genius and labour have adorned individual human beings/ ' 
1 Were it otherwise," he says, " the toil of education would 
have been mitigated, and there would have been no bounds 
to the mental acquirements of the race ; but when our 
first parents tasted of the tree of knowledge, the tree of 
life was denied them, and knowledge perished with its 
possessor." Quite true, knowledge perishes, but not the 
capacity to acquire knowledge. This is increased with 
every generation. Again I must repeat, it is not the 
knowledge that is hereditary, but the tendency to the 



98 THE CAUSES OF INSANITY 

acquisition of some particular branch, whether of music, 
poetry, or money-making. Some element that is necessary 
for these acquisitions is transmitted, and it depends on 
circumstances and education whether that element is 
developed to be of practical use. 

Opinions vary as to the relative importance of heredity 
and education in the production of adult qualities ; by 
heredity being understood all those qualities and capa- 
bilities which exist at the moment of birth, and by 
education all those external influences which are brought 
to bear upon the child from the commencement of his life. 
Some people credit education with powers that are 
altogether beyond it, ascribing to it all the qualities, 
whether good or bad, possessed by the adult ; others, like 
the writer, consider heredity to be the more potent factor. 

Thus an English infant transferred to France and 
brought up by French parents will never be as French as 
genuine French children. The Germans of to-day have 
still many of the characteristics which distinguished the 
Teutons at the downfall of the Roman empire. The 
predominating character of the French race is still that 
of the Gauls described by Caesar : their love of display 
and effect, their sudden enthusiasm and as easy dis- 
couragement, their readiness to be governed by military 
leaders, their fondness for ornament and art, their gaiety, 
fickleness, and amorousness. 

We do not deny that education can do much. Many a 
puny child of the slums can, by means of judicious feeding, 
attain the stature and the build of the country child. 
The mind may be directed so that he who in the environ- 
ment in which he was born would have developed into an 
uneducated member of the proletariat may become a 
man of letters or of science. He who would have readily 
developed into a criminal, a danger and an expense to 
the community, may often, by due training, develop into 
a benefactor of his race. But all these things can only 
be done if the child possesses the natural tendencies to 
develop in these directions. What man can by taking 
thought add one cubit either to his mental or his bodily 
stature ? What teaching could ever raise the congenital 
idiot to the level of common human intelligence ? 

The tremendous adaptability of man has been fully 



HEREDITARY DISPOSITION TO INSANITY 99 

enlarged upon by many writers, and it gives rise to the 
impression that as all of man's mental stock-in-trade is 
acquired, and not instinctive, we can train any child into 
any speciality — that is, if we take a negro child soon enough, 
we can train him to be a Michael Angelo or a Gambetta. 
And this belief in the efficacy of education to make brain 
is held, in spite of the fact that in every institution devoted 
to the education of the lower races, without a single 
exception, the curriculum has to be cut down to the 
mental level of the students. Negroes, for instance, get 
along famously until they reach the higher mathematics, 
and other subjects requiring abstract reasoning, which 
are beyond the mental range of most of them. 

The tendencies to particular forms of virtue and vice 
are hereditary, but not the acts themselves. People 
gradually begin to recognise that a tendency to drunken- 
ness may be transmitted from parent to child, not by 
force of example and education merely, but by direct 
constitutional inheritance; but few will admit that a 
child may similarly inherit a tendency to bad temper 
and all its consequences, as well as many other evil 
inclinations, the same as a tendency to consumption 
or other disease. They recognise bodily defects and also 
all the intellectual ones that limit the range of thought, 
but they continue to talk of the moral powers as if all 
men were born morally perfect. 

If any given person can transmit his like to an off- 
spring — which is a physiological fact beyond dispute — 
surely he must also transmit his like when that like 
is an unstable nervous system. What form that like 
will take must, of course, be greatly modified by 
environment, and by all the numerous unfavourable 
and antagonistic external circumstances and agents to 
which we, as human beings, are subjected. Anyhow, 
there can be no doubt that an " unstable " parent is 
more likely to produce an unstable than a stable child. 
Fortunately, however, this is not always so. We have 
always to consider the opposing factor, and remember 
that it may be the stronger ; were it not for this, the 
world would rapidly become filled with weaklings. The 
offspring charged with unstable germ-cells from, say, 
the father, is equally charged in the reverse way through 



ioo THE CAUSES OF INSANITY 

the mother, and the sum total of these two individuals 
is, in all probability, an individual with the good and bad 
of both parents, but with those qualities probably much 
exaggerated, minimised, or equalised. If this be so in 
the ordinary individual, why not in the " afflicted " one ? 
Are we not bound to believe and accept the fact that in 
certain diseases, for example in insanity, the unhealthy 
parent must beget a child at all events predisposed to 
that disease ? 

Much has been said about the difference observed 
between the various offspring of the same parents, par- 
ticularly if there is one child with habits not to be found 
in either mother or father. But we must not forget, 
just as two elements in chemistry, each of them harmless, 
can combine to form a virulent poison, so two elements 
of themselves harmless, one derived from one parent 
and one from the other, can be inherited by the child and 
form a combination which, if not checked early, may be 
detrimental to its future. The child may inherit the 
characteristics of one parent only, or partly those of 
one and partly those of the other ; or it may exhibit 
the father's characteristics at one time of life, and at 
another time these may be replaced by those of the 
mother. It very often happens that certain individuals 
inherit a prepotency for the transmission of their own 
special characters, which always predominate in the 
offspring to the exclusion of those of the other. 

Another factor in heredity is the tendency to the 
reappearance in the descendants of qualities or defects 
which have been latent or dormant for one or sometimes 
two or more generations. This is known as atavism. 
The latent character may be called into existence by the 
union of an individual in whom it is latent with another 
individual in whom it is potential. As in physical 
heritage all the qualities or lineaments of a parent are 
not equally inherited by the children, but divided amongst 
them, so in affections of the mind it is not always the 
same and entire phase which is represented in the off- 
spring, but this is analysed and the elements dis- 
tributed. In one, we have an impulsive nature, in 
which, between the idea and the act there is scarcely 
an interval ; in another, the proneness to yield to 



HEREDITARY DISPOSITION TO INSANITY 101 

temptation of any kind — a feeble power of resistance 
inherited either from the original or the acquired nature 
of the parent ; in a third, we have an imbecile judgment ; 
in a fourth, an enfeebled, vacillating will ; in a fifth, 
a conscience by nature or habit torpid and all but 
dormant. All these are the normal representatives of 
an unsound parentage, and all are potentially the 
parents of an unsound progeny. 

Circumstances may modify existing tendencies, but the 
advantage will be with the person who has received no 
such taint. How absolutely we are subjected to the 
laws of heredity is shown by the fact that even the 
age to which we are destined to live individually, acci- 
dents of course excluded, is predetermined. The best 
means of attaining long life seems to be to possess the 
requisite constitution. One reads of the centenarian, 
whose death is chronicled in the newspapers, that he 
either smoked all his life or did not smoke, that he worked 
hard in the fields or preferred the less exposed life of the 
town, that he was adventurous or stay-at-home, a 
teetotaler or a moderate drinker, a meat-eater or a 
vegetarian. Like the poetic brain, the capacity for long 
life is an inherited condition. It is one of the most stable 
characteristics transmitted from father to child. So 
much so, that whenever there is a case of extreme old 
age, one may confidently look for the same characteristic 
occurring in other members of the family. 

I feel certain that an offspring seldom escapes untouched 
when both parents are mentally unstable. A mentally 
healthy father may counteract the unstable qualities 
of the mother and may beget mentally healthy children, 
or a healthy mother may counteract unstable qualities 
in the father, with the same good result in the offspring ; 
but I think it is almost impossible for the offspring to 
escape when there is a bad heredity from both 
parents. It is almost bound to tell in the offspring — 
although in many cases far short of actual mental disease 
— to make them neurotic subjects, and even if they 
themselves escape from that appalling disease, insanity, 
they are so slenderly formed from a mental point of view, 
they enter the world charged with a mental inheritance so 
far from stable and perfect, that the subsequent genera- 



102 THE CAUSES OF INSANITY 

tions stand a poor chance. Multitudes of human beings 
come into the world weighted with a destiny against 
which they have neither the will nor the power to con- 
tend ; they are the step-children of Nature, and groan 
under the worst of all tyrannies — the tyranny of a bad 
organisation. 

In many of these cases — certainly in more than half, 
and perhaps in five out of six — there is something in the 
nervous organisation of the person, some native peculi- 
arity, which, however we name it, predisposes him to 
an outbreak of insanity. When two persons undergo 
a similar moral shock or a similar prolonged anxiety, and 
one of them goes mad in consequence, while the other 
goes to sleep, and afterwards gets to. work, and recovers his 
equanimity, it is plain that all the co-operating conditions 
have not been the same — that the shock has not been 
the entire cause of the outbreak of madness. What then 
has been the difference ? In the former case there has 
been present a most important element, which was happily 
wanting in the latter — there has been a certain hereditary 
neurosis, an unknown and variable quantity in the 
equation. 

The family history of the insane is extremely difficult to 
ascertain, not only because people are unwilling to 
admit the presence of insanity in their families, but 
because in the great majority of instances questions 
are solely directed towards the elucidation of a history of 
mental aberration which often does not exist, or is 
unknown. An unstable nervous system, one of the 
numerous neuroses, is all that is necessary. Neither 
need the parents be affected, but somebody amongst 
the ancestry. 

The conclusion of almost every man who has written 
about mental unsoundness is that heredity is by far 
the most frequent and most potent predisposing cause 
of insanity. It commonly underlies all other causes. 
Without its existence there would be very little unsound- 
ness of mind in the world. If all hereditary tendencies 
to mental and nervous unsoundness and defects could 
be counteracted, humanity might breathe freely. It 
must be understood, however, that it is not the special 
mental defect or disturbance that is inherited, but that it is 



HEREDITARY DISPOSITION TO INSANITY 103 

either a general defect of brain nutrition or an instability 
of working in the higher nerve cells ; or it may be that 
the quality of resistance against toxins and other enemies, 
which is an essential part of the healthy constitution 
of all living tissues and organisms, is diminished. Or 
possibly the evil inheritance may consist of individual 
departures from what one may call Nature's " law of 
averages." 

From this premiss it is evident that insanity is not 
a chance occurrence ; there is a necessary preceding 
condition — namely, that the brain of the subject must be 
predisposed by heredity to mental breakdown. It may 
be fairly asked whether the ideally normal man can 
possibly become insane. It is as reasonable to suppose 
that a healthy man is liable to become blind, deaf, or 
paralysed, excluding the influence of accidents, as, with 
the same reservation, that he may under ordinary cir- 
cumstances become mentally deranged. The difference 
between the person who may become insane and the 
person who will not become insane is one almost entirely 
of hereditary predisposition. On the other hand, there 
are unquestionably thousands of predisposed persons 
who escape the graver risks of their faulty inheritance, 
and pass through life untarnished by insanity. 

Insanity as a result of imperfection of brain structure 
may be directly hereditary. It may appear at the 
same period of life in parent and child, and may even, 
as in the case of suicidal impulses, be photographically 
similar in type as well as chronologically equivalent. 
Persons coming of a very neurotic stock tend to insanity, 
especially at the critical periods of life — at puberty, 
adolescence, the child-bearing period, the climacterium, 
and in senility. Stress, vice, drink, toxins, injury, and 
other exciting causes facilitate its advent. 

The parents of the insane on one side or the other 
are often themselves on the borderland of insanity; 
while not exactly over the boundary line, they are 
erratic, peculiar, " nervous/' or otherwise manifest a 
degenerative neurotic tendency. We have in these 
cases what has been called the insane diathesis or psycho- 
pathic disposition — a condition that tends to insanity, 
if not in the individual himself, at least in his descendants, 



104 THE CAUSES OF INSANITY 

Insanity in a parent may reappear in children, as insanity, 
idiocy, imbecility, or other physical or mental defect such 
as epilepsy, chorea, or neurosis of some sort. Insanity 
in a person may also lead to vice or crime in the de- 
scendants, and children of criminal parents may become 
insane. 

The psychopathic inheritance may be derived, not 
only from parents or grandparents in whom actual 
insanity has developed, but from those who have suffered 
from epilepsy, dipsomania, hysteria, etc. There is, 
however, as is well known, no fatal certainty of the 
transmission of mental or other defect ; the children of 
insane parents may escape altogether, or the defect may 
appear in only one or two generations. The danger to the 
children in my experience is directly in relation to 'the 
recency of the insane attack ; thus, a father, having 
begotten healthy children, has an attack of insanity, and 
while still insane, or shortly after the passage of the 
acute symptoms, begets a child which becomes insane ; 
but later, he may beget healthy children. Again, the 
child of a mother who has an attack of puerperal insanity 
may be affected, though the mother did not become 
actually insane till after the birth of the child. Of the 
two parents, the mother is, according to the almost 
universal authority of alienists, the one whose insanity 
is most liable to be transmitted to the child. 

The psychopathic constitution may arise upon a here- 
ditary basis or it may be due to injurious influences 
exercising their effect during foetal life, such as exhausting 
diseases or drunken or other habits of the mother, or it 
may be the effect of acute diseases in childhood. 

Sometimes organisation and education act together 
in the production of psychopathic disposition, as when 
parents transmit to their children not only by way of 
heredity an unfortunate organic constitution, but also 
by force of bad example and defective education. 

Thus, children are born under various conditions, 
and some will be far more liable to nervous disorder than 
others born of the same parents. Some may be born 
before the mother has shown any symptoms of the 
disease, others may be children of one who has been 
insane during her pregnancy or has had repeated attacks 



HEREDITARY DISPOSITION TO INSANITY 105 

of mania. In the case of others, conception may have 

taken place after the father has shown undoubted 

symptoms of mental disorder. Some may be born of a 

mother who becomes insane after every childbirth, and 

only recovers to a very partial extent by the time another 

is born. Such children stand in a different class from 

those whose parents have never been insane, but inherit 

a taint from their own progenitors which shows itself, 

it may be, in brothers, sisters, or other collateral branches. 

Children born before insanity has shown itself in a 

parent are in a better position than those born after, 

and those born of parents in whom the disease has 

appeared at a very early age are more likely to inherit it 

than the children of parents in whom it appeared later 

in life, especially if, in the case of the latter, there was 

an adequate and assignable cause. Those whose parents 

are cousins are liable to hereditary disease. If any, as 

insanity, exists in the family, it will most likely be 

intensified by the relationship, and the offspring are likely 

to be not only insane, but stunted and weakly in other 

respects, and very possibly idiots. In this they but follow 

the laws of inbreeding, which apply equally to man 

and animals. 

Actual kinds of mental disease are not, as a rule, 
transmitted in the same form from the parent to the off- 
spring, although such cases, of course, do frequently occur. 
Although it does not follow that the offspring of a mentally 
affected parent will become insane, there is every likelihood 
that the offspring will be unfortunate enough to be 
possessed of an unstable nervous system. Thus a 
mother who has had an attack of melancholia may be- 
get a child who also may suffer from melancholia, but 
it is much more likely that the melancholic mother 
passes on to her offspring an unstable nervous system 
— a nervous system which at some future period is apt 
to give way, and its owner thus becomes the subject 
of a definite attack of insanity. The unstable nervous 
system, besides being in most cases the gift of a bad 
heredity, is a condition which can be acquired through, 
adverse circumstances, neglected habits, vicious indul- 
gences, etc., with which we shall deal presently. 

If one takes into account only the more serious nervous 



106 THE CAUSES OF INSANITY 

affections, the mistake may be made of supposing that 
the greater number of the descendants of the insane 
escape altogether. But the more carefully the members 
of a neuropathic family are observed, the more evident 
it becomes that the apparently healthy frequently 
manifest trivial forms of neurosis, which are a grievous 
burden to such people, and if their symptoms, regarded 
at any given time, do not appear important, yet the sum 
of their sufferings throughout a lifetime is certainly 
worthy of consideration. 

Insanity depends, therefore, on the predisposition of 
the inherited organisation and the stress of circumstances 
which bear on that organisation. When a hereditary 
tendency exists, it only needs a special exciting cause 
or combination of causes to bring out visible effects; 
but, as will be shown in the succeeding chapters, there 
are modes of upbringing, of education, of conduct in life, 
that should be avoided where a man is specially handi- 
capped by a bad heredity to unsoundness of mind or 
nervous disease. There are special precautions and 
attention to physiological laws which would save the 
minds of many men with a bad heredity from passing 
into inefficiency and actual unsoundness of mind, and 
these, too, will be dealt with in succeeding chapters. 



CHAPTER VII 

THE INCREASE IN INSANITY 

THE EFFECT OF ADVANCING CIVILISATION ON THE 

MIND OF MAN. 
MENTAL AND MORAL CAUSES OF INSANITY 

Considering our present comparative ignorance of the 
relationship between brain and mind, and considering our 
ignorance of the normal working of the brain, can it be 
any wonder that we know next to nothing of its disordered 
functions under pathological conditions, and are helpless 
in preventing the constant increase in the number of 
insane ? 

When a comparison is made over a number of years of 
the proportion of registered lunatics to the total popula- 
tion, the result is distinctly startling. In 1859, for 
instance, the proportion was 1 to each 536 ; in 1889 it 
was 1 to 337 ; in 1904 it was 1 to 288 ; in 1905 it was 1 to 
285 ; and in 1910 it was 1 to 274. What the ratio 
would be if the unofficial and borderland cases were 
included it is difficult to tell. To these figures must 
be added an appalling number of weak-minded and 
backward children, whose fate is very distressing. Of 
the poor, those who are rational enough to be allowed to 
remain at home have, as a rule, not enough sense to earn 
their own living, and those who are wealthy frequently 
become the dupes of others. 

The most important reason for this increase, to my 
mind, is that, notwithstanding the progress made in our 
knowledge of insanity, we have hitherto made little or 
no attempt to arrest the disease before it is fully developed. 
Only patients whose disease is sufficiently advanced for 

107 



108 THE CAUSES OF INSANITY 

certification can be sent to asylums, but we want to treat 
the earlier stages, and the opportunities for such treat- 
ment, at all events as far as pauper patients are con- 
cerned, do not exist. It is true the London County 
Council intend as a beginning to establish experiment- 
ally a Reception House for the acutely insane in London, 
but according to the Council's report it is to be feared that 
it will be a very small affair, entirely inadequate for the 
needs of London. 

Some authorities deny that there has been an actual 
increase in the number of insane persons, and give various 
reasons why they consider the increase is only apparent. 

They say that there is now greater accuracy in identi- 
fying and registering persons of unsound mind, that 
there is greater strictness in carrying the Lunacy Laws 
into effect, and that insane persons who were once be- 
lieved to be harmless and were permitted to wander at 
large are now brought under restraint. They say that 
since the capitation grant of four shillings per head per 
week has been introduced in 1874, more aged, paralysed, 
and weak-minded paupers have been transferred from the 
workhouses and infirmaries to the asylums, and that 
the low recovery and death rates tend to perpetuate the 
lives of the inmates of asylums, and thus help to swell 
the number of insane. We are also told that the public 
have come to regard asylums with increased confidence, 
and hence are more ready now than at any former time 
to commit their friends to a care and custody which they 
have not only ceased to dread, but from which they have 
learned to expect none but beneficial consequences. 

No doubt there is truth in all the reasons set forth to 
account, at least partially, for the vast increase, but 
when all is said, there remains the fact that the county 
and borough authorities are constantly being confronted 
by the necessity for more accommodation in county and 
borough asylums, that new asylums spring up as a result, 
and that the ratepayer has constantly to put his hand in 
his pocket to defray expenses. It will hardly be denied 
that such a condition demands that we should use every 
effort to diminish, if possible at the source, the numbers 
of those who thus become incapacitated, either tem- 
porarily or permanently, who, if not possessing private 



THE INCREASE IN INSANITY 109 

means, become either a burden to their relatives or to 
the community, and who, in some cases, become criminals 
as the result of their mental disorder. 

Insanity is rare before puberty ; twenty-five to fifty 
is the most common age — that is, during the period of 
greatest mental activity, stress, and strain. The ab- 
normalities which appear early in life are chiefly weak- 
mindedness, idiocy, and imbecility. Old age brings with 
it a special tendency towards dementia, but it is not the 
number of years that causes the mental infirmity asso- 
ciated with it, but the arterial degeneration. 

There are special conditions, both physical and moral, 
which dispose to insanity. In women, menstruation 
with its irregularities, childbirth, lactation, and the change 
of life are potent influences. It appears that the pro- 
portion of females admitted to asylums annually is 
actually less than that of men, but women lunatics live 
longer than those of the male sex, and accordingly there 
is a tendency for females to accumulate in such institu- 
tions. Men are more exposed to the various influences 
which directly cause insanity. Alcoholism is more 
frequent with them, the disease known as " general 
paralysis " affects men chiefly, the struggle for money 
and position and the stress qi competition expose men 
more than women, and cause those with unstable nervous 
systems to become more easily subject to mental dis- 
order. But it is not among the highly educated that 
the liability to unsoundness of mind is most prevalent. 
These are as a rule in fair circumstances, and can take 
greater care of themselves. It is among the industrial 
classes, especially in the lower grades, that insanity is 
most frequent, probably on account of their poverty, 
uncertainty of employment, less sanitary life, ex- 
posure to drink, want of reasonable enjoyment in life, 
and probably also because of the lower type of brain 
amongst that class of labourer which caused him to 
sink to that social status and prevents him from rising 
into a higher position. After all, the social and patho- 
logical refuse of mankind, if kept alive, must in their 
own generation or the next degenerate to the lowest 
social position. It cannot be denied that a large per- 
centage of the human family is born into the world so 



no THE CAUSES OF INSANITY 

weakly endowed mentally as to be wholly unfit for any- 
thing but the most primitive form of citizenship. 

There can be no doubt also that the " nervous " tem- 
perament predisposes to insanity. Persons of that 
constitutional peculiarity, even in a normal state, have 
highly active brains and sensitive nerves, enjoying 
pleasures keenly, but also feeling pains and disappoint- 
ments acutely. They have a lively imagination, think more 
and work more, so that they are most apt to exhaust 
their reserve force. Since the brain is most dominant in 
them, injuries and poisons affect this structure more 
readily. The nervous temperament is easily turned into 
a " neurotic " temperament, which cripples power and 
usefulness, embitters existence, spreads wretchedness, 
unfits both men and women for their duties, and 
while this condition is not indicative of insanity, it 
yet differs widely from complete sanity. Amidst and 
arising out of this diffused neurotic atmosphere are to 
be met many individuals exhibiting the early phases 
of mental disorder— individuals who are standing on 
the borderland of insanity, the limits of which, shading 
off imperceptibly into the regions of pronounced in- 
sanity, are more easily passed than traced. 

"Nervousness " is the trouble of the age. Many men 
and women are never really ill, nor well either — that is 
to say, they are never ill enough to consult a physician, 
and never well enough to enjoy either work or pleasure. 
They suffer from forgetfulness, lack of concentration, 
confusion of ideas ; they are restless, irritable, depressed, 
melancholic, and unable to endure any exertion. 

The conditions of modern life are largely responsible, 
more than any other factors, for the increase and ex- 
tension of insanity. It is an acknowledged fact that 
insanity is very much less common among savages 
than among modern civilised nations. An undeveloped 
nervous system can give rise to idiocy and imbecility 
only, and not to insanity ; hence there are no lunatic 
savages, animals, and infants. When a savage race 
comes into contact with modern civilisation, insanity 
increases rapidly. As life grows in complexity, there 
must be an ever-increasing liability to a breakdown on 
the part of the nervous and mental machinery. 



THE INCREASE IN INSANITY in 

There seems no reason to dispute the prevalent im- 
pression that we suffer vastly more than our forefathers 
from the sense of pressure, worry, and unrest. Steam 
has not merely quickened physical movement, but its 
accelerating effect has operated in every department of 
life and manners. The telegraph and telephone mark the 
victory of the nineteenth century over space and time, 
but we pay for the boon in an increased expenditure of 
vital energy. Education has enlarged its scope and its 
claims at so rapid a rate, that already the timid are be- 
ginning to demand a halt. The humble village inhabi- 
tant has to-day a wider geographical horizon, more 
numerous and complex intellectual interests, than the 
prime minister of a petty state a century ago. If he do 
but read his paper, let it be the most innocent provincial 
rag, he takes part, certainly not by active interference 
and influence, but by a continuous and receptive curiosity, 
in the thousand events which take place in all parts of 
the globe. A cook receives and sends more letters than 
a University professor did formerly, and a petty trades- 
man travels more, and sees more countries and peoples, 
than did the reigning prince of other times. 

All these activities however, even the simplest, involve 
an effort of the nervous system and a wearing of the 
tissues. Every line we read or write, every human face 
we see, every conversation we carry on, every scene 
we perceive through the window of the flying express, 
sets in activity our sensory nerves and our brain centres. 
Even the little shocks of railway travelling, not per- 
ceived by consciousness, the perpetual noises and the 
various sights in the streets of a large town, our suspense 
pending the sequel of progressing events, the constant 
expectation of the newspaper, of the postman, of visitors, 
cost our brain wear and tear. Hence the educated classes 
suffer more from nervous diseases, whereas the uneducated 
lower strata, who are subjected to other influences that 
affect the mind more, increase the number of the insane. 

The struggle for a more comfortable and therefore more 
exacting existence must be carried on by the brain. In 
this struggle the brain becomes finer in its organisation 
and more creative ; at the same time it becomes more 
vulnerable, and is more reactive to stimuli which only too 



xi2 THE CAUSES OF INSANITY 

easily lead to over-stimulation, with consequent ex- 
haustion, disease, and degeneracy. These increased de- 
mands of the struggle for existence exercise their effects 
to-day upon the brain of the individual even at the desk 
in school, and the concurrence of all these influences in 
the domains of art, science, and industry, with the desire 
for luxury and riches, keeps a great part of modern 
society in a condition of constant nervous strain and 
excitement. 

These injurious influences show themselves in the 
predominance of the neuropathic constitution in modern 
society, which has " nerves," but too little " nerve." 

The influence of culture and competition on the pro- 
duction of insanity is shown by the following example : 
The teir Italian provinces that have the greatest number 
of insane in proportion to the population are all in the 
industrial North ; the proportion varies from 25*3 to 
1 6- 9 per 10,000 - inhabitants. The twenty-two Italian 
provinces that show the smallest number of insane in 
proportion to the population are all in the agricultural 
South, the proportion varying from 1*3 to 6*6 per 10,000 
inhabitants. 

One of the reasons why uncivilised people are less prone 
to insanity may be that they lead a simpler life. They 
are not subject to political or religious storms and have 
no refined pleasures of life, but are given to a natural 
mode of living. 

Civilisation favours the occurrence of insanity through 
the enormous growth of population of great cities with 
the resultant evil influences, hygienically and morally ; 
the increase of a mentally and physically degenerate 
proletariat, pauperism, predominating factory life, lack 
of marriage, the increasing intellectually and morally 
destructive craze for riches and luxury, and the greater 
struggle for existence. Men live in crowded cities under 
unnatural conditions, and perfect mental or moral 
development cannot be the rule so much as in healthier 
surroundings of village or country life. In these latter, 
too, the average mediocre intellect can find its medium, 
in which it can safely thrive, while it would be much 
more likely to succumb if transplanted into the hurry and 
bustle and the fierce struggle for existence of city life. 



THE INCREASE IN INSANITY 113 

Faulty education may predispose the child to nervous 
and mental diseases. Thus too strict and harsh treat- 
ment of an impressionable and emotional child, who is 
sensitive and in need of loving care, lays the foundation 
for a faulty adaptation to the world and to a retiring, 
melancholic disposition. On the other hand, an education 
that is too solicitous, which can deny nothing and excuses 
everything, cultivates obstinacy, unbridles passions and 
emotions, engenders defective self-control and inability 
to practise self-denial. Too early awakening and strain 
of the intellectual powers at the cost of the emotions, of 
childish simplicity and bodily health is another cause. 
This cause makes itself doubly felt where brilliant and 
often one-sided capabilities, as they occur in neuropathic 
and hereditarily predisposed children, excite the pride 
of parents and guardians, and lead to overstrain of the 
mental powers of the precocious child ." In this way the 
foundation may be laid for later insanity. 

According as the infant has been treated considerately 
and consistently, or has been thoughtlessly, impatiently, 
and fitfully regarded, so will necessarily his feelings have 
been affected and his temper formed. If petted at one 
time and snubbed at another, now treated as having 
both feelings and intelligence, and anon as though he 
had neither the one nor the other, his temper will partake 
of the same fitful nature. As is the sowing, such will be 
the harvest. 

The children of the upper classes are generally con- 
signed for their early training to the care of dependents, 
who, even if not ignorant, neither feel nor could be 
inspired with the same sense of responsibility as parents. 
This custom is responsible for some of the bad results in 
neurotic children. 

The march of education demands that more shall be 
learned, and competition on every hand and in every 
walk and calling perpetually urges men to fresh efforts 
and new paths of enterprise. It is believed that the con^ 
sequent exhaustion resulting from this over-tax on the 
brain renders the nervous system more liable to disorders 
and disease. 

Society life, the excitements of all sorts that it occa- 
sions, the physical fatigue that it brings on, and that 
8 



114 THE CAUSES OF INSANITY 

almost inevitably result from the habit of too long and 
too copious meals in rooms that are often over-heated, 
the late hours and insufficiency of sleep — at least, of sleep 
at the proper times — frequently cause the development 
of nervous exhaustion. Nothing is so enervating, nothing 
so fitted to unbalance and weaken the nervous system, 
as to be wholly taken up with the pursuit of pleasure 
and the satisfaction of the least elevated and least noble 
desires. Social life demands self-control and submission 
to the majority, power of resistance to the storms of 
life, and resignation. Where these qualities are wanting, 
there is no escaping disappointments, bitterness, and 
pain. Sometimes "the later rough school of life makes 
up for defects of education and forms the character ; 
but this cannot occur without great trouble, which 
threatens, in many instances, the mental equilibrium. 

Intense or too prolonged intellectual work may give 
rise to symptoms of fatigue and depression, but they 
are neither persistent nor grave. Hard work, whether 
physical or mental, is not only harmless, but it is actually 
healthful. The hard- worked muscle, whether of arm 
or heart, responds to the stimulus, and receives an 
accession of vigour and development. The hard-worked 
brain, if placed under favourable conditions for its activity, 
becomes more vigorous and fruitful. Indolent inactivity 
of body or mind is undoubtedly far more injurious to 
both physical and intellectual vigour than severe labour, 
provided only that the labour is pursued under health* 
ful conditions of food, air, rest, and sleep. 

Men seldom, if ever, go mad from intellectual activity, 
if it be unaccompanied by emotional agitation. De- 
pressing emotions constitute a much more serious source 
of fatigue than brain work. It is the worry that has 
preceded, accompanied, or followed it that is of im- 
portance. The brain-work that over-drives and exhausts 
is that which accompanies care for the morrow, worry 
caused by an end to attain, or fear of failure, whether 
the matter at issue be one of industrial or commercial 
affairs in which the fortune is engaged, or one of an 
examination or competition on which the future depends. 

In the fierce struggle for existence, which there neces- 
sarily is where the claimants are many arid the supplies 



THE INCREASE IN INSANITY 115 

are limited, those who, either from inherited weakness 
or from some other debilitating cause, are unequal to 
the struggle will, some of them, break down in madness. 
We wear ourselves out not by hard work, but by anxious 
thought regarding the adjustment of work, and by nervous 
irritation attempting to accomplish an impossible task. 
By worry is generally meant harassing preoccupation 
with matters upon which no amount of taking thought 
can be of the slightest avail, and usually with regard 
to questions which are not deserving of the anxiety 
bestowed upon them. Some people are born worriers. 
Their minds are engrossed with small points that irritate 
them, or filled with apprehensions of what is about to 
go wrong. 

Speaking generally, the more mechanical and the 
more purely a matter of routine the character of the 
work, the less likely is the stress to fall on and damage 
the bodily health. The more close, continuous, and 
vigilant the application of attention to the work, the 
more liable is the stress to produce insanity. It has 
been shown that insanity is not prevalent among the 
victims of the sweating system, long as their hours of 
work are and excessive as is the demand made upon 
their energies by the exigencies of their means of liveli- 
hood. These conditions may lead to phthisis and to 
other forms of breakdown of bodily health, but rarely 
to insanity, and the reason for this exemption is to be 
found in the character of the work, which is of a purely 
routine and mechanical nature. 

When occupations in which the attention is closely 
engaged are pursued to an excessive degree of absorption 
of time and energy, the breakdown that ultimately 
results is very apt to lead to insanity. We find that 
in those cases of insanity which are attributable to 
overwork, the work needs close attention, and there 
is anxious worry as well. Such is the work of pre- 
paring for examinations, when the distress comes 
usually from having too large a number of subjects, 
beyond the power of the student to master within a 
given time, that " preys on the mind." It is work 
attended by great anxiety, anxiety being constant 
attention plus apprehension. For this reason it is that 



Il6 THE CAUSES OF INSANITY 

precarious occupations are more detrimental to sanity 
than those in which the livelihood is secure. Men who 
are in no danger of losing their means of livelihood are 
free from one of the severest forms of anxiety. It is 
when to a high degree of precariousness of the means 
of livelihood is added a great demand for close and 
vigilant attention in the daily work that the greatest 
danger to sanity arises, and consequently it is the daring 
speculator, the man who is daily hazarding his fortune 
and position in some project which requires a great 
absorption of attention and exertion, whose work exposes 
his mental health to the severest stress. 

Emotion and passions are psychical phenomena, but 
their result is a disturbance of the vaso -motor and trophic 
processes which, initiated by the brain, regulate the 
nutrition of the tissues. Through this disorder of in- 
nervation toxic products are developed in abnormal 
amount, and they being carried in the blood stream 
implicate the nervous system and disturb its functions. 
The facts of tired feelings and sleep after prolonged 
mental or physical exertion confirm this theory, the 
toxic products of muscular exertion passing into the 
circulation and so reaching the nerve-centres. This is 
a process of physiological auto-intoxication. 

Insanity often begins in mental conditions, which may 
at first be perfectly sane and normal, but by undue 
continuance or undue intensity they establish grooves 
of thought so deep as to create a disturbance or per- 
version of normal brain activity which in time becomes 
truly morbid. 

The person may have started life like his neighbour, 
with a sound, evenly balanced brain ; he is perhaps in 
later years exposed to severe strain ; his work, business, 
or profession, demands excessive care and thought, and 
he is subjected to an undue amount of wear and tear. 
Through stress of business he neglects Nature's laws, 
he becomes careless about his mode of living, neglects 
to care sufficiently for his body, is careless about his 
meals, shuns exercise and recreation, " burns the candle 
at both ends," all for the sake of his work. His only 
thought is for his work, and finally he breaks down in 
health. He is now no longer the same person : what 



THE INCREASE IN INSANITY 117 

would not have worried him before does so now ; what 
before was natural manly anxiety becomes restless un- 
easiness, perhaps even actual depression ; he commences 
to lose interest in things, becomes easily annoyed, appre- 
hensive, and perhaps irritable ; he is now apt to com- 
pletely break down and to become affected mentally. 
It is the persistence of the emotion which reacts un- 
favourably upon the nervous system. The consequent 
worry interferes with the functions of nutrition, disturbing 
digestion, preventing sleep, and excluding the pleasur- 
able sensations which always accompany the healthy 
working of the organism. This, apart altogether from 
the depressive action of the emotions upon the cerebral 
circulation and the nutrition of the brain, facilitates 
in predisposed persons the advent of mental dis- 
turbance. 

Another way in which a disagreeable emotion may 
cause insanity is by suddenly overwhelming the subject. 
It happens occasionally that the apparent beginning 
of an attack of insanity dates from a mental shock, 
fright, the hearing of bad news, the death of a dear friend, 
or some other strong or sudden cause of emotional excite- 
ment or disturbance. The psychic effects of such are 
so well known that it is needless to dilate upon them, 
and it is therefore the more easy to conceive how they 
can produce mental derangement. It is possible that 
this cause is, as some have suggested, more common 
than is generally supposed. 

Other painful emotions that sometimes affect un- 
stable brains arise from domestic troubles, disappoint- 
ment in love, religious excitement, and personal griefs 
or losses. 

The married state may create dangers for the mental 
health, in that the characters of the husband and wife 
may not be congenial. The need to support a family 
makes greater demands upon the mental and physical 
activities. Misfortunes of all kinds during the struggle 
for existence may change anxiety to despair. Faults of 
character, expensive or flirting habits, and hysteria in, 
the wife may destroy the husband's peace of mind ; 
while brutal treatment, drunkenness, and unfaithfulness 
on the part of the husband may affect the wife. On the 



Ii8 THE CAUSES OF INSANITY 

other hand the better hygienic conditions of a happy 
married life exert a prophylactic influence. 

All " prolonged " emotions exhaust the brain and may 
get out of control. Thus, excessive anger may lead to 
acute mania ; excessive fear to melancholia ; excessive 
suspicion to delusions of persecution ; excessive conceit 
and vanity to delusions of exaltation. Love, passion, 
jealousy, avarice, may all get out of control by being too 
ardently indulged in. All of them have a contracting 
effect on the personality, tend to keep the thoughts in 
one groove, on one set of ideas or objects, and that a 
narrow one. When to this is added some derangement 
of the physical system, still further contraction follows. 
The patient's attention is now demanded by bodily 
sensations, which are good servants, but bad masters, 
and which become more and more insubordinate the 
more they are humoured. A patient in this condition 
is like a person living always in one small room with the 
blinds down — self-centred and miserable. 

Of course it shows that brains so susceptible to emotions 
of sorrow, anxiety, love, or jealousy, and so easily 
moved to extremes, must have been always sensitive 
and unstable. There must be a flaw in the brain-con- 
stitution somewhere. But the flaw need not be an 
hereditary one, for these anxious emotions lower the 
health and weaken mental control. If any one be 
subjected, for example, to adverse circumstances for 
any length of time, to business worry or strain, financial 
difficulties and the never-ceasing worry of an unhappy 
domestic life, even the strong, stable, healthy-minded 
man will be that no longer. He has acquired just those 
conditions of neurosis which are apt to cause a mental 
breakdown. The most interesting and obscure forms 
of mental disease are those which begin gradually, 
progress slowly, and are in reality a slow evolutionary 
change in the person's character. 

Only too often does it happen that the laity regard 
the last and striking link in the chain of causes as the 
only cause, and thus ignore the effect of all previous 
and less prominent influences. Loss of business, death 
of a dear one, excesses of various kinds, are looked upon 
as causes, when actually scientific investigation shows 



THE INCREASE IN INSANITY 119 

that heredity and weakening diseases were the true 
etiological factors upon which the former acted, and 
thus were effective in bringing about the catastrophe. 
We must take into consideration the general mental and 
physical individuality, for often mental disturbances 
are only the final results of all previous states of life and 
development. 

Much depends on the reserve nervous force, the reserve 
energy, a man possesses. Take the man who is stren- 
uously and eagerly working to support his family, who 
is having a struggle "to make ends meet," would not 
the receipt of bad news or some financial loss affect him ? 
He might, for the time being, shun society and seek 
instead the privacy of his own home. But if the man 
be strong mentally, his worry and anxiety will show 
themselves in a manly way ; he will in time throw them 
off and gradually rise above his temporary misery. If, 
on the other hand, he has little reserve stability, is 
naturally gloomy, and of a nervous and morbid nature, 
his anxiety, which was at first quite legitimate, will 
slowly drift into a confirmed condition of anxiousness 
and fear ; he next becomes depressed, and finally passes 
into a condition of true melancholia. While his sus- 
picions, anxiety, and fears remain, he has now lost all 
sense of proportion, cannot control himself, and from 
this the transition is easy to almost any kind of mental 
disease. Such is indeed a common story and one of 
everyday experience. 

Another cause of the increase in insanity is the pre- 
mature discharge of insane patients from asylums. We 
have to face the fact that annually there are being turned 
out of the asylums a number of recovered, partially 
recovered, or unimproved patients corresponding roughly 
to from 25 to 50 per cent, of the several admission 
rates ; of these nearly 58 per cent, are women — about 
75 per cent, of whom are at the child-bearing age — and 
42 per cent, men, nearly all (90 per cent.) of whom are 
at the reproductive age. In the pauper asylums the 
large majority of these people are of the poorest class, 
mostly improvident, poorly educated, absolutely ignorant 
of the malignant powers they possess, and abominably 
careless as to what their intercourse may lead to, what 



120 THE CAUSES OF INSANITY 

their progeny may be, what degree of physical or mental 
impotence their children may inherit, how these shall 
live, who will have to support them, or what poverty- 
stricken, unhealthy, immoral, or secluded lives they 
may have to lead. 

Worry is one of the commonest precipitating causes 
of mental disease, and the worry attached to endeavour- 
ing to restart life, entirely unassisted, as is the lot of too 
many of those who are discharged from asylums, must 
certainly count for much in the frequency with which 
ostensible recoveries prove to be only temporary. It 
need scarcely be said that, quite apart from their mental 
condition, many of those who are discharged from asylums 
as cured stand badly in need of assistance. Their 
previous illness has often wrecked their careers ; they 
have lost their homes and friends, and it is not easy for 
them to find work, owing to acts committed whilst their 
insanity was developing, and to return to their former 
neighbourhood and former position is not only repug- 
nant to their sense of self-respect, but is also often 
impossible, owing to unjustifiable popular prejudices, 
hence many of them have to begin life over again. 

In a large number of cases a patient had before his 
attack a trade by which he made his living, and some 
savings and resources to meet the needs of his wife and 
children. The disease seizes him, his wife and children 
are scattered to seek support, his resources are exhausted, 
his business is gone, and we know how difficult it often is 
for a healthy man to re-establish a business. The diffi- 
culty is greater for the recovered lunatic, against whom 
arise obstacles of every kind. He is distrusted, his 
recovery is discredited, and the lack of confidence is in 
some cases only marked by the fear he inspires. 

Moreover, not a few require rest in the country for a 
time, under favourable conditions, as regards food, air, 
and companionship. Ordinary convalescent homes, how- 
ever, refuse to admit persons on discharge from asylums, 
so, in default of special arrangement, many must take up 
the struggle for existence, so far as they can, the moment 
they leave the asylum premises. Many men and women 
return to poor homes, where deprivation and want cause 
them to break down again, and even in favourable 



THE INCREASE IN INSANITY 121 

circumstances long residence in asylums — the same as 
in prisons or any other institutions — has destroyed that 
feeling of initiative and self-reliance and, above all, that 
healthy independence which is so necessary for success. 

The very causes that led to the original attack in a 
mind not over-strong and possibly predisposed to mental 
disease are all the more operative after collapse has already 
occurred. By careful supervision after discharge such a 
recovered patient may be prevented from overdoing, 
may be removed from a depressing or unhealthful en- 
vironment, and may be so favourably situated that a 
second attack will never recur, and the individual himself 
remain a productive member of society. 

At one time, when a patient was discharged from the 
asylum, it could be said : 

Wither he went and how he fared, 
Nobody knew and nobody cared. 

Now there is an " After-Care Association " devoting 
itself to endeavouring to facilitate the re-entry into 
ordinary life of persons of the poorer classes when dis- 
charged from asylums as recovered; but, like all such 
organisations, it stands in need of adequate funds. 

The After-Care Association is intended to afford pro- 
tection to the indigent insane discharged as recovered from 
the asylums. Assistance to save these persons from want 
is not their only object. Their object is rather to protect 
the discharged patients from the manifold causes which 
may lead to their relapse, to guard them from the troubles 
that will assail them from the moment they are brought 
in contact with the outside world. 

The methods of the Association, in brief, are as follows : 
The secretary of the society visits the asylums and 
works in close co-operation with the medical superinten- 
dents, and is notified by them when there are patients to 
be discharged cured, who are poor, and who have no 
homes nor friends to go to. For such cases boarding- 
places (in the country for the women and in the city for 
the men) have been arranged for. These are small 
cottage homes where a man and his wife are willing to 
board these after-care cases. There are now, I believe, 
about twelve of these cottage homes in different parts 



122 THE CAUSES OF INSANITY 

of England. The board of both men and women is paid 
for by the society for from one to six weeks, usually until 
employment is found for them. The society keeps in 
communication with them often for years, until they are 
absorbed into the community as self-supporting, self- 
respecting men and women. 

In conclusion, something should be said of the con- 
tagion of insanity. It is popularly believed that those 
who have to do with and care for the insane are them- 
selves specially liable to be similarly afflicted. Indeed, 
the danger of association with lunatics is often very 
great, for sometimes whole families are affected by one 
genuine insane, and it is well known that asylum physi- 
cians after years of association with lunatics have them- 
selves become affected. The contagion is purely mental, 
through the influence of association, and generally implies 
a pre-existing mental weakness or predisposition on the 
part of the recipient. Such communicated or imposed in- 
sanity is the imposition by a stronger mind on a weaker 
one of its own delusions. It is generally observed in 
cases of very close association and relationship, as be- 
tween parent and child, brothers and sisters ; and the 
communicated insanity is very generally cured by re- 
moval from contact or association with the imposing 
agent. 



CHAPTER VIII 
INEBRIETY AS A CAUSE OF INSANITY 

Besides heredity, alcoholism of the parents is so common 
an element in the family history of the mentally defective 
or deranged as to be justly counted as a predisposing 
cause, and one of the most important. It is especially 
manifest in the causes of idiocy, imbecility, and epileptic 
insanity, a very large proportion of the victims of these 
afflictions having a history of parental intemperance. 
Opinion varies as to whether the habit of drinking is 
itself inheritable. It seems to me that if intemperance 
were as common in the female as in the male sex, it 
would, as a cause of insanity, be much more important 
than it is at present ; but so long as the mother is an 
abstainer, the danger is not nearly so great. 

Alcoholic parents tend to have degenerate children. 
Idiocy, imbecility, moral perversion, and epilepsy are 
most frequent amongst them. The curse of drunkenness 
has done much to demoralise the human race mentally, 
morally, and physically. Its debasing and degenerating 
influence has been especially marked among the lower 
classes, and has had much to do with their moral degra- 
dation. The children of drunken parents are born into 
the world with a defective nervous organisation, and 
such weak inhibitory will-power as to make them an 
easy prey to the trials and temptations which beset them 
on every hand. With a weak mental endowment they 
easily gravitate into the many highways and byways of 
sin, and early become a charge in one or other of the 
public institutions. 

On the other hand we must not forget that since many 
people drink to excess because they are not quite sound 
mentally, we do not know how many of the children of 

123 



124 THE CAUSES OF INSANITY 

drunkards are hereditarily affected for the reason that 
their parents drank, and how many because their parents 
were originally unbalanced in mind. That a drunken 
father, and more certainly still a drunken mother, does 
produce idiotic and epileptic children I have had absolute 
proof in my own experience. 

It might be asked how it is, as so often happens, that 
a chronic alcoholic may have offspring mentally and 
physically sound. The answer is wrapped up in the 
causes which lead a man to drink, and observations seem 
to show that a man who can drink continually for a 
number of years, and keep out of a lunatic asylum, a 
prison, or a hospital, must possess an inherent stable 
physical and mental organisation. The virility of his 
stock remains potent in spite of his vicious habit, 
although it is undeniable that his offspring, in all proba- 
bility, would have been stronger and better had he 
been a temperate man. 

Many lunacy specialists hold the opinion that insanity 
is largely due to drink, ignoring the two dominant facts 
that insanity is on the increase and that drinking is not. 
My experience has taught me that the number of insane 
owing to intemperance is comparatively small, but that 
the defective self-control of persons inclined to insanity 
often leads to drink, and even a glass or two in such 
tainted persons may produce the appearance of drunken- 
ness. Alcoholic drink in moderation may do no harm 
in the healthy, but it is " rank poison " to unstable 
brains and brains that have been injured or are diseased. 

To no class of persons is intemperance more dangerous 
than to those inheriting an unstable nervous system. The 
researches of numerous investigators have shown that, 
speaking generally, the insane, the weak-minded, the 
epileptic, and those who have sustained grave head in- 
juries are susceptible in unwonted degree to the evil 
influences of alcohol. Persons so afflicted are poorly 
equipped with power of resistance, either because of 
defective hereditary endowment or because factors in 
their early development have rendered them unduly 
susceptible to toxic substances, so that they are pro- 
foundly affected by an amount that would only cause a 
mild exhilaration in a more stable organisation. For 



INEBRIETY AS A CAUSE OF INSANITY 125 

such unstable persons there can be no half-way course. 
They cannot be temperate. Such persons must be total 
abstainers, or else must suffer the slow physical and 
mental deterioration that alcohol inevitably produces 
in such individuals. Those who have had previous 
attacks of insanity are more easily upset by drink than 
others who have not had previous attacks. Some 
neurotic persons may be driven mad by a sudden bout 
of drinking ; others are upset after long series of de- 
bauches. 

So complicated are the causes of mental disorder, that 
it is necessary to point out that the true cause is a de- 
fective heredity which provides the subject with a con- 
stitution which is particularly susceptible to the influence 
of such poisons as alcohol, and induces the subject to 
crave for a particular mental state — not for alcohol, but 
for the state that alcohol most conveniently produces. 

Alcohol is unable to initiate insanity except in certain 
predisposed subjects. This is shown by the fact that 
although drinking to excess is very common in the 
community, the percentage of cases which develop insanity 
under the influences of this stress is very small. The 
predisposing factor is an inborn instability of the nervous 
system, or, in other words, a congenital structural defect 
of this tissue. 

The deleterious effects of alcohol are far more liable 
to affect other viscera than the brain, such as the liver, 
which becomes cirrhotic, yet cirrhotic livers are rarely 
met with in insane alcoholics, so that only persons with 
an inherently stable nervous system can drink long 
enough to acquire alcoholic cirrhotic livers. 

A list of reasons for imbibing was once given in Punch, 
which showed the absence of a guiding rule. One man 
took a glass because he was merry, and another because 
he was sad ; one man because a friend had come to see 
him, and another because his friend had left him ; one 
because he had a daughter married, and another because 
he had a daughter buried ; one because he had a rising, 
and another because he had a sinking ; and so on. 

It is not of these minor and temporary causes of which 
we wish to speak here, but of the deeper reasons for 
drinking which produce harmful effects and may lead 



126 THE CAUSES OF INSANITY 

the person to become a " drunkard." All the reasons 
advanced by our temperance advocates have a good deal 
of truth in them, but would not drive a man to drink 
unless he is already a " weak character." He takes to 
drink not so much from outward as from inward causes, 
by reason of his defective mental constitution. 

It is not everybody who can become a drunkard ; 
there must be a nervous predisposition, frequently 
hereditary. At the present day, when drunkenness is 
looked down upon as disgraceful by the better and more 
educated classes, excessive drinking has vastly diminished. 
It is fair, therefore, to conclude that, while what we may 
term as unbalanced temperaments and instincts of self- 
indulgence are inherited, the actual way in which these 
instincts will manifest themselves depends upon the 
surrounding conditions which may happen to prevail. 

Some people seem to think that craving for drink is 
created by the sight or presence of a public-house. Yet 
they have only to ask themselves how it is that they pass 
the public-house not only with indifference, but with 
loathing, and it will be born in upon them that their 
contention is somewhat faulty. The truth is that nobody 
becomes a drunkard from choice or accident. Before a 
man takes to drink as a vice he has a taste for it, a pre- 
disposition which grows out of some physical defect, 
constitutional in the first instance, but liable to be 
aggravated by poor food, unwholesome surroundings, 
bodily wear and tear, and loss of moral tone. 

Doubtless a few cases of alcoholism can be attributed 
solely to force of example, but even in those one must 
consider the brain-disposition of the person upon whom 
the example exerts its influence. Several people may be 
thrown open to the same examples and temptations, and 
yet it is probably only the minority that succumbs, and 
is this not on account of the different susceptibility or 
instability of the brains of those in question ? 

As far as the poor are concerned, the only place where 
they can meet their equals, where they can gratify their 
cravings for sociability, where they can discuss the 
topics of the day, and have a break in the monotony of 
their daily existence, is at the "public-house." Often 
it is the only place for a man, and even for a woman, to 



INEBRIETY AS A CAUSE OF INSANITY 127 

escape to from a miserable small tenement, a big family 
residing in one or two rooms, or a bachelor living in a 
lonely lodging. The well-to-do man may have one or 
perhaps two drinks with his friend in his home or at 
his club, and can take his time over it. Not so the poor 
man. The conditions are such that the poor man is 
tempted, if not forced, to go on drinking. The exterior 
of the public-house is gaudy, but any anticipation of 
cheering comfort which the inexperienced customer 
might entertain is forthwith dispelled when he enters. 
The publican may have a comfortable and spacious 
sitting-room for himself and his attendants. The un- 
fortunate customers, on the contrary, are shut out from all 
this by a high zinc-covered counter, and are allowed only 
small standing room between the counter and a draughty 
swinging-door. The floor is often dirty, and in most 
places no seats are supplied. Proper tables are out of 
the question, and often a barrel is used as a substitute. 
In this narrow, uncomfortable, wet, and cheerless place 
the customers, and especially the working-class customers, 
are obliged to stand while they take their refreshments. 
While a continental working-man takes his refreshment 
at his ease, seated in a comfortable chair, with a small 
table to himself or his friends, attended by a smart waiter, 
with access to a goodly supply of newspapers, the British 
working man has to take his refreshment at an exorbi- 
tant price at the sloppy zinc counter, and is there treated 
like an animal drinking from a trough. There is of 
course an object in this arrangement, and it is to en- 
courage a constant relay of comers. There is little 
inducement to linger, and so soon as a man has finished 
his glass he feels that he is in the way, or he is bluntly 
asked what he will take next. In this way his feelings 
are worked on to induce him either to leave or renew his 
order. It is by improvement of the public-house, by 
giving the poor man in the public-house the advantages 
which the rich man enjoys at his club — comfortable 
rooms, tables and easy chairs, newspapers, etc. — that 
we can reduce the tendency to drunkenness. But We 
are doing just the opposite. Comfortable restaurants 
have no licences ; they cannot serve alcoholic drink at 
all, or bottled beers and wines only, which must be 



128 THE CAUSES OF INSANITY 

taken together with food, hence the competitors of the 
public-house find it difficult to exist. 

Is it a wonder that what attracts the attention of 
foreigners in our big cities the most is a sight to which 
they are totally unaccustomed in their own country, the 
sight of " drunken women " ? Drunken men too are 
seen more than elsewhere. Sometimes there is a fight, a 
life is taken, and the man — who originally only intended 
to take a glass of beer — is condemned. But the zeal of 
teetotalers is often extreme. They go too far when they 
say that crime, insanity, and every kind of misfortune 
are due to drink. 

As regards crime, premeditated crime is rare amongst 
drunkards, but misdemeanours and crimes committed in 
passion, and while under the influence of alcohol, are 
common. Therefore, if we reduce drink, it is by no means 
certain that we reduce dangerous criminality. A criminal 
may drink for "courage" before his deed, in reality to 
blunt his moral sentiments and conscience ; but if he takes 
too much he will be all the more readily discovered. 

As regards the association between drink and immo- 
rality, this is particularly true of women. The women 
who drink to excess lose their feeling of shame. Unwonted 
alcoholic indulgence by young girls has been, in the great 
majority of instances, the first step in the downward path. 
On the other hand, most immoral women drift, sooner or 
later, into a condition of chronic inebriety. 

Large numbers of women charged with chronic drunken- 
ness are unfortunates living upon the streets and whose 
calling brings them into conflict with the police. Women 
of this class cannot possibly benefit, so far as their 
reformation is concerned, by detention in inebriate re- 
formatories. Their health may be improved, but their 
animal passions are strengthened, and they return to 
the streets on their release. Properly speaking, these 
women are not inebriates at all ; they are dominated by 
sexual passion, which absolutely controls them. 

The results of reformatory treatment of inebriates 
are disappointing. From the histories of 1,900 inebriates 
who had undergone reformatory treatment, only 331 
(according to Dr. Branthwaite, Inspector under the 
Inebriates Acts for England) did well after discharge, 



INEBRIETY AS A CAUSE OF INSANITY 129 

or were said to have recovered, and this although a 
number had been at liberty for less than a year, so that 
even this small number would be less had all been under 
observation for an adequate time. 

I believe too that great harm has been done to the 
cause of temperance by denouncing weak alcoholic 
drinks and strong spirits undiluted indiscriminately as 
all bad. The drink question requires to be approached 
with less passion and fanaticism. But the concerted and 
widespread efforts which have been made to enlighten the 
public as to the harmful effects of the excessive and 
habitual use of alcoholics, either as a beverage or as a 
substitute for food, although not always wisely directed, 
and in many respects fanatical and lacking in proper 
proportion, have none the less exercised a mighty influ- 
ence. 

Most liquors are taken for the sake of the effect, and 
not because they taste nice. Indeed to many people they 
are so nauseous that it requires a good deal of resolution 
to swallow them. To the temperate man and the 
abstainer drink offers no allurements, it satisfies no 
craving, it yields them no delight, and has for them no 
temptation. They are sober not on account of their 
superiority of resistance, but because not being tempted 
to desire, they do not fall. Many persons could not get 
drunk if they tried. They are drink-proof, not because 
of any superior virtue, not because of any superiority of 
self-control, but because drink holds out to them no 
temptation. Others have such unpleasant sensations if 
they exceed a small quantity of alcohol that they are 
compelled to leave off long before they have taken 
enough to make them drunk. 

It used to be thought that there was some subtle 
influence in beer or spirits which leads those who begin 
by taking one glass to advance to two, ten, or twenty 
glasses. But closer observation has shown that the risk 
only arises with weak or defective characters. It is in 
the weak-minded person that the habit of drinking creates 
a morbid desire for more drink, overcomes the will, 
blunts the moral sensibilities, and makes everything 
subservient to its demands, until the habitual intoxicating 
cup thrusts itself perpetually on his thoughts, gradually 



130 THE CAUSES OF INSANITY 

so occupying them as to exclude all other ideas. The 
resistance and prayers of his friends are of no avail ; he 
declares he is driven by irresistible necessity to strong 
drink — " he will go mad without it." 

There is nothing on earth that we can take to excess 
with impunity. Even the most wholesome food when 
consumed in excessive quantities will do harm, still more 
so such drinks as tea and coffee, not to mention ginger- 
beer and other beverages, falsely described as non- 
alcoholic. After all, most of the light lager beers con- 
sumed in Germany and some of the British " dinner 
ales " contain very little alcohol, except when manufac- 
tured for export, and since the German beer is kept on ice, 
it forms a cool and most refreshing drink in summer, and 
is much more wholesome than many of the lukewarm and 
insipid beverages consumed by our abstainers. Amongst 
those who consume choice wines, drunkenness is also rare. 

It is true that our forefathers perhaps drank a greater 
quantity of alcoholic beverages than we do, but they 
drank wine containing a small percentage of alcohol and 
their drinks were less adulterated. To-day alcohol is 
found in more concentrated form, the wines, excepting the 
very expensive ones, have little grape-juice in them, 
and the adulterated stuff has been made cheaper and 
therefore within the reach of everybody. 

Undoubtedly water is the most harmless drink, and 
no ingredient is needed; but it is not always easy to 
get good and refreshing water, except in mountainous 
countries. 

The State gives the right to sell all sorts of drink 
among the poor ; the State should also do its best to 
protect the poor from its influence. Earlier closing of 
public-houses would send a good many people to bed 
sober — a thing to be desired ; but better still would it be 
if the State insisted on the absolute purity of drink 
supplied to the poor. 



CHAPTER IX 

TOXIC AND OTHER CAUSES OF INSANITY 

The primary seat of the mental disturbance is not 
always in the brain itself. The brain by means of its 
nerves is in direct or indirect connection with all the 
bodily organs. Hence it is possible that a brain intrin- 
sically sound may show some morbid mental manifesta- 
tions for the sole reason that the stimulations reaching 
it from other parts of the body are not normal. If the 
brain is really normal, such disturbances only arise with 
difficulty, or at any rate they pass away on cessation 
of the cause. Where the disturbances persist, there is 
always some weakness in the central organ. 

We know that bodily conditions will affect the nutri- 
tion of the brain and modify its functions. At one time 
all looks bright, cheerful, and encouraging ; at another 
time, not far distant, the same identical prospect looks 
cheerless, gloomy, and tinted with despair. This change 
depends upon physical conditions. 

When there exists a condition of good nutrition of 
the brain centres, we experience a pleasant, agreeable 
sense of well-being, which shows itself very distinctly 
in after-dinner geniality, cordiality, and generosity. When 
the nutrition is imperfect, the consequences are a mixture 
of irritability and bad temper, blended with depression. 
This is seen in common life, and we are all familiar with 
the crossness of the hungry man. 

The brain can be influenced by actions going on in 
the bodily organs in quite another way — viz. through 
the circulation. A diseased organ may contaminate the 
blood with abnormal products and through the circulation 
affect the nerve elements. Therefore it is one of the 
first points we investigate in any case of mental dis- 

131 



132 THE CAUSES OF INSANITY 

turbance, whether the internal organs and functions are 
in good working order or not, and whether there are any 
poisons circulating in the blood and so affecting the brain. 

Often there is poisoning of the blood and the mind 
centres by a deleterious substance, or a starvation of them 
by insufficient or bad food. This toxaemic origin of 
insanity has of late assumed a position of great im- 
portance. In the minds of some, toxic action is the main 
factor, and the large majority of cases of insanity are 
nor primarily diseases of the brain at all, but are dependent 
on the toxic action of adverse bacteria which most com- 
monly originate in the alimentary canal. 

Among the intoxications it is usual to distinguish 
those which are due to the introduction of poisons from 
without, from those which are produced in the organism 
itself. The distinction, however, is not well defined, for 
the poisons which are introduced from without may 
produce chemical disturbances and also lesions of organs 
which may ultimately lead to a real internal intoxication. 
Again, the effects produced by the infections do not 
depend so much on the direct action of the micro-organ- 
isms themselves, as on the poisonous products, the toxins 
which they supply, or which are formed in the organism 
as a result of their action, and which injuriously affect 
the nervous structures. 

Sometimes infections leave no evident disease behind, 
but only a weakness, an unhealthy condition, which later, 
under the influences of other causes, may give rise to a 
true mental disorder. The infection may also act as a 
stimulus to a latent predisposition. 

When the toxic substances which are associated with 
the causation of mental disorder arise from the excessive 
formation of morbid waste-products, products of disordered 
metabolism within the body itself, they are then known 
as auto-intoxicants . Their number is increased particularly 
in deficient nutrition or starvation, after operations which 
have been followed by considerable loss of blood, after 
febrile diseases, as well as in long-continued wasting 
diseases. In the extreme form they set up a delirium 
known as delirium of inanition. 

The principal symptoms are loss of sleep, followed by 
great restlessness and clouding of consciousness. The 



TOXIC AND OTHER CAUSES OF INSANITY 133 

patients lose a clear idea of their surroundings and do 
not recognise their friends. Actual hallucinations soon 
mingle with the altered perception of things, generally 
of a depressing character. The patients are anxious ; 
warnings of death or other fear-inspiring visions are 
seen. There is confusion of ideas. The talk is incoherent 
or the patient repeats meaningless phrases, seemingly 
disconnected portions of sentences, as if the ideas were 
broken off in the middle. The delusions may change 
rapidly, the patient being in a sort of paradise one moment 
and smiling, and the next moment he is in hell, with 
terror on his countenance. The active motor agitation 
renders it very difficult to keep the sufferers in bed. The 
patient frequently seeks to escape, shows bold aggressive 
motions, impulsive acts of violence, immodest behaviour, 
and unreasoning resistance as far as his weakness will 
allow. Under treatment the cloudiness of consciousness 
disappears, and as the physical condition improves the 
other mental symptoms subside. 

Since the symptoms pass away when the cause ceases, 
such patients should not be certified as insane. Only 
when the symptoms persist, as they do where the brain 
was originally defective, are we justified in treating the 
person as mentally deranged. 

Typhoid fever and pneumonia are, next to meningitis, 
the infective processes that most readily induce mental 
disturbances. 

In typhoid fever we have two distinct phases of mental 
disorder — one occurring during the acute febrile stage 
and the other appearing during convalescence. The 
nervous symptoms in some cases of typhoid fever com- 
pletely overshadow all others, and the patient maj^ rapidly 
pass into a condition of raving mania due to toxaemia. 
In other cases the patient may pass into a condition of 
wakefulness, with hallucinations of vision and hearing, 
and even delusions. Later there will be a stage of pro- 
found mental prostration, or a condition of imbecility or 
stupidity may ensue, lasting for several weeks. The 
other important mental change is the one of post -typhoid 
insanity, caused no doubt by nervous exhaustion and 
insufficient food, and it must be borne in mind that mania 
may follow ordinary starvation, 



134 THE CAUSES OF INSANITY 

A patient suffering from pneumonia is liable to sudden 
frenzy, and may attack the nurse or patients, or may 
even throw himself out of a window without any warning. 

Of the various infective diseases, influenza is also one 
that opens up the way for the development of secondary 
mental disturbances, especially in the form of neuras- 
thenia with fixed ideas (Chapter XVI) and melancholia 
(Chapter XIX). 

The action of the products of disordered metabolism 
usually manifests itself in persons who are predis- 
posed by heredity to suffer from nervous diseases, for 
their organism and products grow only upon a suitable 
soil. We are thus driven back to the constitutional taint, 
the inheritance of an unstable nervous system as the 
chief factor in the production of insanity. Both sane 
and insane may suffer from similar toxaemia ; but whereas 
the brain of the sane man is stable so that the toxines 
produce no mental symptoms, the brain of the insane 
man is unstable, and readily becomes disordered by toxic 
action. Both pathologists and psychologists have there- 
fore arrived at the same result. The former say that two 
persons may have their blood in a toxic condition, and 
only the one whose brain is unstable will show symptoms 
of insanity. The latter say that two persons may receive 
a mental shock and be subjected to prolonged stress, and 
only the unstable person will manifest insanity. Given 
a high degree of tendency to a morbid reactiveness in 
the cortical cell from a bad heredity in any brain, it will 
be subject to mental disturbances from any kind of un- 
usual stimulus, whether it be mental, toxic, or otherwise. 

The auto-intoxication can also arise where there is 
retention of products which should normally be elimin- 
ated, deficient destruction of the primary products of 
metabolism, followed by their accumulation in the system. 
Thus there are nervous and mental disorders associated 
with diabetes and gout. 

In diabetes the patient is irritable, fretful, and im- 
patient. Later he becomes suspicious and distrustful 
of those around him, and may even develop delusions. 

In gout we have unreasonable irritability and sus- 
picion, intolerable bad temper, and anxiety. Such 
patients are the terror of their domestics. 



TOXIC AND OTHER CAUSES OF INSANITY 135 

Lastly, there are the organic and inorganic poisons 
introduced into the system voluntarily, or by accident. 
Amongst the poisons introduced from without, the most 
important is alcohol (see Chapter XXIII). This, as 
well as other poisons, such as opium, morphia, cocaine, 
is introduced voluntarily for the sake of the exciting 
effects which it produces. Other poisons, like lead, 
find their way into the system in the exercise of some 
occupation which exposes the person to a continuous 
contact with the toxic substance. 

Amongst the internal secretions necessary in right 
quantity for a healthy condition of the blood is the 
secretion of the thyroid gland. When this secretion is 
in excess it produces exophthalmic goitre (Graves' or 
Basedow's Disease), a disease with very marked phy- 
sical symptoms and some mental disturbance. The 
most common feature is an intense and indefinable 
agitation leading to a more or less marked motor and 
mental restlessness which causes the patient to look for 
constant change in his surroundings and work. There is 
an inability to settle for long to any one occupation or 
recreation. A sudden noise, any unexpected news, any 
of the ordinary disturbing elements of everyday life, may 
be followed by an attack of palpitation lasting for some 
hours, and yet these patients want to keep moving. 
They are frequently emotional, ranging from grave 
to gay, from marked depression to joyous buoyance, 
without any adequate reason. There are occasionally 
' volubility," considerable mobility of ideas, easy flow of 
language. Often the moral nature too is altered, and 
the patient becomes untruthful, spiteful, and suspicious. 

When the secretion of the thyroid gland is deficient, 
we get a disease called myxoedema, again with definite 
physical signs and some marked mental peculiarities, 
consisting chiefly of a retardation of all the mental 
processes. 

Most bodily diseases have certain mental features 
which may become so well marked as to interfere with the 
ordinary mental life, and to take their places as character- 
istic symptoms of the particular disease. 

The temper of the patient is singularly modified by 
different disorders and diseases. The state of despon- 



136 THE CAUSES OF INSANITY 

dency in abdominal complaints forms a remarkable 
contrast with that of hopefulness in chest complaints. 
We do get depression sometimes in serious lung diseases, 
but it is not the rule ; and such cases can be attributed 
to the gravity of the situation and the anxiety naturally 
associated with an intelligent comprehension of the 
danger impending. As a rule there is hopefulness as 
irrational as is the depression in some other affections. 
The consumptive patient, just dropping into the grave, 
will commonly enough indulge in plans stretching away 
far into the future, ignoring alike his real condition and 
the improbability, nay, even impossibility, of any such 
survival as he is counting upon. Hope seems to rise 
above the intelligence, just as in certain abdominal 
diseases there is a depression which successfully defies 
the corrections of the intelligence. 

Disordered heart's action is another cause for insanity, 
as one would naturally expect when the blood supply of 
the brain is irregular. Whatever disturbs the healthy 
action of the brain may become an exciting cause of 
insanity in those so disposed. Persons labouring under 
heart disease are very apt indeed to suffer from doubtful- 
ness, caprice, vague fears, dreads, and suspicions that 
cannot be explained in any other way than by the reflex 
effect on the mental part of the brain when this great 
organ is in a condition of disease. The heart has always 
been put down as the seat of the emotions. It is certainly 
not so, but it is equally certain that the emotions specially 
affect the heart's action, and that certain emotions are 
" felt " in the region of the heart. It has become part of 
literature to talk of " the heart " in opposition to " the 
head." There is really no such opposition, but, on the 
contrary, the closest connection. To say that a man's 
head is weak, but that his heart is alright, when trans- 
lated into physiological language means that a man's 
intellectual centres in the brain are not strong, while his 
emotional centres are extra well developed and sensitive. 

There is no special form of insanity associated with 
kidney disease, but in the later stages of chronic Bright's 
disease the brain seems to participate, until it is violently 
overcome by the uraemic poison. The patients are often 
found crying, and on inquiry they exhibit marked de- 



TOXIC AND OTHER CAUSES OF INSANITY 137 

lusions of fear and suspicion ; often they are delirious, 
restless, irritable, and show mental failure, until coma 
terminates the scene, preceded by convulsions. When 
uraemia supervenes, there are at first restlessness, head- 
ache, insomnia, then the patient rapidly passes into a 
violent stage of mania, with delusions of fear and sus- 
picion. 

The immorality common to urban life spreads one 
particular disease — syphilis — which has a most far- 
reaching and disastrous effect on the brain and nervous 
system. These effects sometimes appear five, ten, or 
twenty years after infection. The poison weakens the 
entire nervous system so that it succumbs more readily 
to disease. Locomotor ataxia and general paralysis 
(Chapter XXII) are the two nervous diseases most 
common in such patients. The scourge of this disease 
has been the most deadly enemy to the upward pro- 
gress of the human race the world has ever seen. Its 
disintegrating power in destroying |iuman life has been 
greater than even plague and war. 

The children of parents affected with the primary or 
secondary stages of this disease are born with hereditary 
syphilis. A large proportion of them die of convulsions 
and meningitis. If they survive a few weeks or months, 
the disease reveals itself by defective development, 
slowness of growth, and even at adult age such subjects 
are often stunted, and the brain or other parts of the 
body may show arrested development resulting in idiocy, 
imbecility, or simple weak-mindedness (Chapter XXVI). 
Epilepsy may also occur. 

Premature and abnormal sexual habits are also weaken- 
ing to the resisting power of the nervous system, and 
therefore often cited as causes of insanity. 

In women, predisposed to insanity, there are two 
what we call " exciting " causes. These are the puerperal 
and lactational periods (Chapter XXIV). It is evident, 
therefore, that everything promoting health during these 
periods, and all the principles which aim at placing even 
working women under hygienic conditions during their 
term of maternity, will constitute preventive measures 
against insanity. 

Then there are such physical causes as heat-stroke 



138 THE CAUSES OF INSANITY 

from exposure to the direct rays of the sun upon the body, 
especially upon the head, and from excessive artificial 
heat, as in the case of firemen and stokers on large 
steamers. Sunstroke and heat may predispose towards 
mental disease, or their immediate effect may be a 
hallucinatory-confusional type of insanity. 

Insanity sometimes occurs after a surgical operation, 
and is not always due to inanition. For instance, ampu- 
tation of an arm or leg does not give rise to mental dis- 
turbance, yet operations on the ovaries, rectum, bladder, 
and prostate frequently do, for they affect the sympa- 
thetic nervous system which has to do with the emotional 
nature of man. 

Brain- turn ours and large haemorrhages in the brain 
may produce mental as well as physical symptoms through 
increased intracranial pressure (Chapter XIII). 

An important cause of insanity in a considerable number 
of cases is injury to the head (Chapter XIII). I know, 
from actual experience in my own practice, that such in- 
jury, although often trivial, leaving sometimes no external 
sign on the head, can yet cause serious mental disturbance. 
In my book on The Mental Symptoms of Brain Disease 
I have shown that the type of insanity varies in accord- 
ance with the region of the brain injured, and have 
cited some eight hundred cases in support of my view. 
The insanity which follows head injury may appear 
immediately after the accident, or there may be only a 
change of disposition and character for some time ; but 
in a great many cases the insanity occurs only years 
after, and yet patients can be restored by surgical opera- 
tion when the seat of injury can be localised. Not every 
history of a fall or blow on the head can be verified, for 
many relatives are fond of imagining such a cause in 
place of a more serious one ; on the other hand, it is my 
conviction that in many asylum patients there is a 
history of injury to which no attention has been paid, 
and who might have a chance of recovery if an operation 
were undertaken. 

Another cause which, in my opinion, has been under- 
valued, at least as regards frequency, is the injury done 
to the individual at birth owing to the pressure of a badly 
applied forceps, producing haemorrhage in the brain of the 



TOXIC AND OTHER CAUSES OF INSANITY 139 

newly born. In my out-patient practice I have seen 
quite a number of children bearing the scars of such 
injuries on each side of the head. Labour in civilised 
races has become more difficult ; the pressure to the 
child's head in a narrow pelvis, or from prolonged labour 
at the period of birth, as well as the injury by the 
careless or unskilful use of forceps, account for some of 
the cases of idiocy. It is a fact that cases of idiocy are 
more numerous among males than among females, and 
this may be in some measure due to the fact that the 
male head is larger than the female, and therefore likely 
to receive more pressure. 

One cause productive of idiocy or feeble-mindedness 
is attempts to secure abortion. Where that is instru- 
mentally attempted without success, injury may be done 
to the head of the foetus, and where drugs are used, these 
may disastrously interfere with its nutrition and growth. 

Another cause is the practice of artificial, insufficient* 
and improper feeding of infants, especially amongst the 
poor, which leaves the survivors to continue the struggle 
for existence with constitutions seriously weakened and 
impaired. A child born perfectly healthy, and of healthy 
parents, but half-starved during the whole period of its 
infancy, is liable to grow up imbecile or demented owing 
to an unnourished brain, or a brain badly nourished, 
during the growing period. Often intestinal irritation is 
set up, and this in infants, with any tendency to nervous 
instability, brings on convulsions which retard cerebral 
development. Infantile convulsions often merge into 
epilepsy, which again in a large proportion of cases 
causes mental disorder or enfeeblement. 

Febrile diseases in infancy and childhood are respon- 
sible for a certain number of cases of mental defect ; 
meningitis is a common cause, and so is fright, cruel 
usage, and educational over- pressure. 

Finally, there are many cases of mental disease in 
which we are not able to find out or assign any cause at 
all, whether from without or within. We know that a 
cause must have existed, but it was so little evident as 
not to come within the reach of even careful investigation. 
It has to be remembered that after all we are only on the 
threshold of unravelling the mysteries of brain and mind, 



140 THE CAUSES OF INSANITY 

If, as the author believes, the brain is not a single organ, 
but a combination of different organs, specifically dis- 
tinct, the cause of insanity may be a want of harmony 
in the development of particular cerebral centres or 
organs, and in such a case the possible combinations are 
innumerable. This condition would also account for the 
observation that in some forms of insanity no patho- 
logical change has so far been discovered. Indeed, the 
causes we have enumerated, whether mental or toxic, 
are only exciting causes ; the predisposing factor, the 
organic anomaly which renders the brain vulnerable, is 
by far the most important but must remain a mystery 
until we know more of the normal brain and its functions. 



PART III 

THE PREVENTION AND TREATMENT OF 

INSANITY 



i 4 i 



CHAPTER X 

THE MENTAL FUNCTIONS OF THE BRAIN 

What can we do to prevent mental unsoundness in 
persons with a bad heredity or a distinct tendency ? 
What can we do by way of treatment during an attack 
or in case of chronic mental weakness ? How can we 
prevent the recurrence of an attack, and what shall we 
do with the incurables ? These are the questions we 
have set ourselves to answer in the succeeding chapters. 

To solve these problems satisfactorily, a knowledge 
of the human brain and its mechanism is most essential ; 
secondly, a knowledge of practical psychology and 
human nature in all its varieties, which can only be 
gained by long experience ; and thirdly, we must be 
acquainted with the manifestations of unsound mind and 
perversities of character. 

Of all the organs in the human body, the brain ranks 
highest in importance ; yet, strange to say, until about 
a century ago it received hardly any attention, and even 
at the present day the knowledge of its mental functions 
is still very obscure. Most of the knowledge of the 
functions of the brain is derived from experiments on 
living animals, which have produced valuable results for 
the neurologist who has to deal with disorders of motion 
and sensation ; but they have produced next to nothing 
of value to the psychiatrist, whose business it is to study 
disorders of the mind. Nor can it be wondered at, for 
even if the animal brain has the same correlation to 
psychical activities as the human brain, we cannot pro- 
duce a thought or feeling at the point of the scalpel, and 
we must ever fail by this method to shed light on the 
nature of mental derangements. It is believed by some 
experimenters that large portions of an animal's brain 

143 



144 PREVENTION AND TREATMENT 

can be scooped out without any effect on its mentality ; 
yet it is well known that a trifling injury to the brain 
of man may render him insane. 

Clinical experience is, after all, the most important, 
and it has already taught us a good deal. 

By clinical observation it has been ascertained that 
all mental operations take place in and through the 
superficial grey matter, or " cortex," of the brain. Or- 
ganic life, nutrition, circulation, excretion, secretion, 
motion, in fact all vital functions, can be carried on 
without the cortex of the brain ; but the manifestations 
of the intellect and moral sentiments, the affections and 
propensities or instincts of self-preservation, cannot take 
place without it. Provided that the cortex of the brain 
be not affected, all the other portions of the system may 
be diseased, even the spinal cord may become affected 
without the mental functions being impaired. Of course 
if the heart, the medulla oblongata, or some other vital 
part be injured, death will succeed any such experiment. 
If, on the other hand, the superficial grey matter of the 
brain becomes compressed, irritated, injured, or des- 
troyed, the mental functions get partially or totally 
deranged or become wholly extinct. When the com- 
pression of the brain is removed, as in the case of an 
indented skull and tumours of the brain, or the extra- 
vasated blood or accumulated pus is evacuated, or the 
cerebral inflammation allayed, consciousness and the 
power of thought and feeling return. 

The mistake that is often made is that mind is regarded 
as if it consisted of intellect alone, whereas we all feel, 
as well as think, with our brains. If it were not so, 
those animals with larger brains than ourselves would 
have to be more intellectual than any human being. 

We think and feel, rejoice and weep, love and hate, 
hope and fear, plan and destroy, trust and suspect, all 
through the agency of the brain cortex. Its cells record 
all the events — of whatever nature — which transpire 
within the sphere of existence of the individual, not 
merely as concerns the intellectual knowledge acquired, 
but likewise the emotions passed through and the 
passions indulged in. We can only manifest our intel- 
lectual aptitudes, moral dispositions, and tendencies to 



MENTAL FUNCTIONS OF THE BRAIN 145 

self-preservation through the mechanism of the brain 
with which we happen to be endowed and according to 
the sort of experience we have accumulated. Hence, 
though the primitive mental powers and fundamental 
anatomical parts of the brain of all men are the same, 
we all vary according to the mental predispositions and 
brain-types we have inherited and the early education we 
have received. 

Other things being equal, the greatest amount of mental 
capacity and vigour is allied to the largest quantum of 
cerebral substance. All observation proves that the 
energy of any nervous centre always bears a direct pro- 
portion to its bulk, whether absolute or relative. Every 
organ of our body increases in size, in proportion as it is 
exercised within the limits of its physiological capacity, 
and this holds good as to the brain as well. With in- 
creased mental work the brain will show an increased 
growth ; hence the cranial capacity is often seen to be 
greater in the insane than the sane, the constant mental 
exercise increasing the size of the brain. 

The head of a new-born child is from 13 to 14 inches 
in circumference ; those of adults are found to vary 
from 21 to 23 inches ; female heads average 1 inch 
less. The entire brain may be too small. Thus, if 
we find a circumference from 14 to 17 inches in an 
otherwise well-proportioned head of a boy twelve years 
old, we may expect so small a size to be accompanied 
by a greater or lesser degree of stupidity or fatuity, 
more or less inability of fixing the attention on a par- 
ticular object, vague sentiments, indeterminate and 
transitory affections and passions, an irregular train of 
ideas, speech consisting of broken phrases or merely of 
substantives or verbs, as — to eat, to walk, to play, etc., 
blind and irregular instincts, or an almost entire absence 
of them. 

Heads of 18 or 18J inches in circumference are 
small, yet if well balanced are not incompatible with the 
regular exercise of the intellectual powers. They in- 
dicate a pitiful mediocrity, a slavish spirit of imitation, 
credulity, superstition, that species of sensibility which 
by a trifle is raised to the height of joy or plunged in 
an abyss of tears, a very fallible judgment, an extreme 

10 



146 PREVENTION AND TREATMENT 

difficulty in discerning the relation of cause and effect, 
a want of self-control, and frequently, which is a happy 
circumstance, but few desires. With this degree of 
development, however, there may exist some marked 
mental aptitudes — such as a remarkable memory for 
figures, dates, music, etc. — because some cerebral part 
may be more fully developed. 

As a rule, when the brain is too small, it is not dwarfed 
equally in all its parts, but is specially so in the frontal 
regions — in those parts which manifest the peculiarly 
human faculties and sentiments — while the hinder and 
lower parts of the brain are far less affected. Were 
the brain developed equally in all its parts, the idiot or 
imbecile would be also incapable of manifesting any 
emotion, whereas on the contrary his emotions are mani- 
fested all the stronger from lack of the inhibitory control 
of reason. 

Though the brain may be represented as a unit, yet 
it contains innumerable centres with in- and outgoing 
fibres, and fibres which connect them altogether, a net- 
work of intricate organic paths, along which a stimulus 
started may travel in countless, but not indefinite, 
directions. All the fundamental kinds of psychical activity 
are carried on in more or less distinct parts of the cerebral 
hemispheres. These centres represent organically every 
minute detail of knowledge and experience ; they register 
every definite observation and thought, and every process 
of reasoning with which the individual has at any time 
made himself familiar ; they represent every sentiment 
and emotion, every affection and passion, and indeed 
every one of those mental processes which are needful 
for the display of what constitutes mind and character. 
There is the same order in the organisation of the cere- 
brum as in every other organ, the same physiological 
division of labour in which all organisation consists. 

Not very many years ago localisation of function was 
considered impossible because of the supposed uniformity 
of the structure of the cortex of the brain. It is through 
the microscopical studies of recent years that the locali- 
sation theory has gained its most notable victory. Since 
1874 a large number of investigations have been under- 
taken into the formation of the grey matter of the brain, 



MENTAL FUNCTIONS OF THE BRAIN 147 

with the result that it was discovered that the brian 
surface consists of various strata of cells, and that there 
are histologically highly differentiated regions and areas, 
not only as regards the cellular elements and cell types, 
but as regards the structure of the fibres. Although these 
investigations have been carried on for close upon forty 
years, the most valuable results have been gained only 
during the last two or three years, so that they are still 
little known and not yet sufficiently appreciated. 

Without entering here into technical details, for 
which see my work on The Mental Symptoms of Brain 
Disease, I mention here a few facts which throw light 
on the problem of localisation. 

Throughout the mammalian series there occurs in 
definite localities of the brain-cortex the same char- 
acteristic structural formation, so that we can define 
homologous areas in the different animals varying only 
in extent. On transverse section the cortex of the 
brain shows a number of distinct regions of peculiar 
structure varying firstly as regards thickness, secondly 
as to the appearance of the cells in the various layers, 
and thirdly in quality. The cortex contains, therefore, 
a multiplicity of organs, of differentiated structural 
complexes, which we are led to assume from the analogy 
of other organs to have separate functions. Forty-eight 
distinct areas have been made out, having identical struc- 
ture in man and animals. This topographical differentia- 
tion of areas is the first step towards localisation. 

For the purposes of our investigation it matters little 
whether these psychical functions are complex or simple, 
whether they have a " predilection " for a circum- 
scribed and histologically distinct part of the cortex, 
or whether they are the " resultant " of numerous 
minor processes all over the brain, or whether all the 
elements of a complex psychical function are to be 
found associated with a particular centre. This must be 
a question for future discussion. All we need agree 
upon, for the present, is that there is a relationship be- 
tween certain parts of the brain and certain psychical 
states and qualities. 

In my opinion, and I must insist on repeating it again 
and again, it is because of the non-recognition of this 



148 PREVENTION AND TREATMENT 

principle of the localisation of mental functions that so 
little progress has been made both in the study and 
treatment of brain disease and mental disorder. 

Many physiologists recognise only centres for move- 
ment and sensation, optical, acoustical, and other areas ; 
but we must not forget that behind those sensory and 
motor centres there lie also all the functions which 
constitute mental phenomena. The fact is overlooked 
that man has a much larger and by far more complicated 
brain than the lower animals, although he has not 
anything like the amount of muscular energy and power 
which many of them possess. 

There are some who still hold that all knowledge is 
derived from sensation, and that therefore the sensory 
brain-centres, such as the centres for sight and hearing, 
are the centres for the intellectual operations, quite 
ignoring the fact that animals and savages have keener 
and in many respects more perfect senses than civilised 
man, and should therefore, if this view were correct, be 
his superior in knowledge and understanding. Why 
should the sensory region be just the intellectual region ? 
The feelings and passions can be aroused just the same, 
and much quicker, as the result of the objective percep- 
tion gained through the medium of the eye. 

Every decided advance in the knowledge of the locali- 
sation of functions has been due to the careful collection 
of cases with autopsies and the study of their common 
features. It is by the observation of clinical and patho- 
logical data chiefly that we can hope to discover the 
mental functions of the brain and their localisation. 

Post-mortem investigations alone without a study of 
the patient while alive are unsatisfactory, for the disease, 
in a person who died insane, has converted the edifice of 
the mind into a mass of ruins, and the pathologist is 
almost in the same position as a man would be who were 
to inspect fireworks on the morning after the show is 
over. The living phenomena are gone, and with them 
the key of explaining the meaning of the structural 
changes. Nor can the bacteriologist or physiological 
chemist explain the working of the human mind, inde- 
pendent of the physician. The things they have found 
are discoveries of great importance, but they explain only 



MENTAL FUNCTIONS OF THE BRAIN 149 

the proximate and not the essential cause of insanity ; 
they are the sparks, as it were, which ignite the fireworks. 
A knowledge of the igniting impulse and a study of the 
remains of the fireworks are extremely useful, but they 
do not explain the combustion. For this purpose we 
must actually witness the display, and this is done by 
the physician, who attends and treats the living patient. 

Just as we have elementary feelings in common with 
animals, but are distinguished from them by our greater 
intellect and higher sentiments, so we have some parts 
of our brain in common with animals and some which are 
distinctly human. If we take the lowest animal which 
has a rudimentary brain and observe its gradual develop- 
ment throughout the whole species till we reach the 
highest apes, we shall find that parallel with the gradual 
development of the reasoning capacity so there is a 
part of brain, corresponding to the frontal lobes in man, 
which increases in size and is relatively largest in the 
gorilla, chimpanzee, and orang-outang, and reaches its 
highest development in the human being. Since the 
other lobes of the brain in man and animals show no 
such disproportion, we may draw the inference that the 
frontal lobes are related to functions which are distinctly 
human, that they are the instruments for the higher 
intellectual operations and the highest human sentiments. 
This is confirmed by various other observations. 

If we study the growth of the human brain in the 
embryo, we find that those parts which are the latest 
and highest acquisitions grow last, and just as the re- 
flective and reasoning faculties are the latest to arrive 
at perfection, so the frontal lobes are the last to develop. 

If we examine the brain of microcephalic idiots, we 
find that the arrested development is chiefly in the 
frontal lobes. Indeed, if we compare the frontal lobes 
of imbeciles with those of men distinguished for their 
intellectual qualities, we find a great contrast in their size, 
though the remainder of the hemispheres has attained 
to normal growth. 

We also find that when the frontal lobes are destroyed 
by injury or disease, the intellectual processes become 
defective and the instincts and passions get beyond 
control. On the other hand, we do not find, when other 



150 PREVENTION AND TREATMENT 

parts of the brain are destroyed, leaving the frontal lobes 
intact, that the intellectual powers suffer at all, or at 
least not to the same extent. 

For purposes of confirmation we may also quote the 
results of experiments on dogs and monkeys which have 
shown that, after destruction of the frontal lobes, the 
curiosity to observe, which is so marked in them, is 
lost ; that they are not able to receive new impressions 
or to remember or reflect on the old ; and that since they 
can no longer discriminate, they become timid and easily 
excited. All the emotions and propensities remain 
intact, only increased in activity for want of control; but 
they show no longer gratefulness, cannot adapt them- 
selves to new surroundings, neither learn anything new 
nor regain what they have forgotten. Experiments on 
animals thus confirm our view that the frontal lobes are 
the centres of perception and reflection and the centres 
for the higher sentiments, so far as their rudimentary 
existence can at all be demonstrated in the lower crea- 
tures, and that they are, in addition, centres of inhibition 
against the instinctive impulses. 

Numerous other facts can be adduced in support of 
the view that the frontal lobes are the centres for the 
purely intellectual operations. Thus the expansion of 
the frontal lobes in men engaged in intellectual pursuits 
has been repeatedly demonstrated by actual measure- 
ments, and it has been repeatedly shown that the frontal 
lobes vary in size and weight in different races according 
to their intellectual capacity. 

The size of the entire head shows the mental power 
only, but not the mental correctness. The town clock 
may operate with a degree of power in proportion to its 
size, and may be heard resounding throughout a whole 
city, exercising thereby a widespread influence, and yet 
a small watch may excel it in point of correctness. Like- 
wise, a little man with a small head may excel in correct- 
ness a big man with a large head by reason of a more 
perfect proportion of the several parts of the brain and 
a better cultivation of his mental powers. But not in 
every case where the size, shape, and quality of the brain 
prove favourable will the mental operations get well 
performed, for there are other things which impart 



MENTAL FUNCTIONS OF THE BRAIN 151 

unusual energy or impede the activity of the brain. The 
digestion, circulation of the blood, or other functions 
may be out of order, and exert an exciting or deteriorating 
influence on the brain, however well proportioned. 

Until recent years it was believed that the shape of 
the skull had no relation to the shape of the brain. Now, 
however, there is not an anatomist existing who would 
deny that the size and shape of the skull is for all practical 
purposes a fair index of the size and shape of the brain. 
Without committing ourselves to phrenology, it is highly 
advisable that more attention be paid to the shape of the 
head. We have learned a great deal during recent years 
about the microscopical appearance of the brain in health 
and disease, but as regards the naked eye appearance of 
the brain, the relative value of the development of its 
different parts, there is still profound ignorance ; not only 
so, but there is no genuine interest in the subject. We 
have great experts as regards the histology and patho- 
logy — that is to say, the post-mortem appearance of the 
brain ; but the living head has interested the expert of 
brain and mental diseases so little that one would expect 
the organ of the mind was anywhere but in the head. 
It is curious that dog-breeders and stud-owners should 
know so much of the heads of the animals they breed, 
and that men who have a thousand or more human beings 
under their care should have made no observations as 
to the significance of particular types of head. It is no 
exaggeration to say that over twenty-five per cent, of all 
insane present abnormal heads, and if the author's ex- 
perience is worth anything, their study will prove most 
valuable to the better understanding of the patients and 
their mental states. 

Every attempt should be made to solve this problem 
of the mental functions of the brain. The treatment of 
insanity will not be perfect until we have acquired such 
knowledge. Such is my view based on a close study of 
the entire history of brain research from its origin at the 
end of the eighteenth century to the present day. 

We shall refer to this subject again in Chapter XIII,, 
when we describe the effects of injury to the brain, of 
circumscribed haemorrhage, the growth of tumours, etc., 
and their method of treatment. 



CHAPTER XI 

MENTAL DISCIPLINE AS A PREVENTION OF 

INSANITY 

Some good should certainly come out of every practical 
attempt to work the brain on right lines, to point out the 
causes of brain and mind failures, and to anticipate some 
of the effects of evil heredity, bad environments, and 
disease. It is for the physician to observe and give 
advice as to what precautions can be taken. Those who 
are able to observe such individuals from birth, and advise 
concerning their bringing up, their schooling, and entry 
into the World, may do much to save them from the 
hereditary scourge. If we want to prevent insanity, we 
must commence with the children (see Chapter XIV). 
From the earliest stage we may note symptoms which 
should put us on our guard. Neurotic children require 
careful management in the upbringing. The infant may 
sleep badly, may be cross, restless, or over-excitable, or 
have infantile convulsions. There are other conditions 
of a contrary nature, but still marking disease, where there 
are stupidity, lethargy, slowness of movement, a diminution 
of sociableness, a lessening of the normal desire to please, 
and a general lassitude of mind. 

As soon as the child shows signs of mental activity, 
two conditions will attract attention. The child may be 
backward or he may be precocious. The backward will 
be slow to grasp what he is taught ; such a boy or girl 
requires special tuition. It is useless to place them in a 
class with others whom they resemble only in age, and 
expect them to do the same lessons and compete on 
perfectly equal terms. The competition of the defective 
child with the normal child is disastrous to the former, 
and results in a condition of hopeless inferiority. Special 

152 



MENTAL DISCIPLINE 153 

teachers are required who will not lose their temper, but 
will, with patience, bring forward what talent may lurk 
in the backward mind. Many backward children have 
a special aptitude for some one pursuit, as music, drawing, 
carpentering, or even mathematics or mechanical en- 
gineering, and it is the teacher's business to discover this 
and develop it by every available means. Masters and 
mistresses are apt to mistake inability for idleness, and 
to unduly press and punish the backward child, assuming 
that because one subject is well learned it is mere idleness 
that prevents all being equally well done. 

On the other hand there is the precocious child, bright, 
quick, and intelligent, apt to learn, and the pride of his 
teachers. This precocity is often born of a neurotic 
stock, just as is the backwardness of the last mentioned, 
and it demands as much care. He is often encouraged 
to compete for places or prizes at school, which increases 
his tendency to nervous disorder. He should rather have 
manual training, and learn to associate knowledge with 
ability to do something. His training should not be so 
much stimulating as inhibitory. 

The facility with which some scholars learn without 
any very apparent effort is not always due to superior 
power, but sometimes to habit of controlling and con- 
centrating their thinking faculties. He who possesses 
this inestimable power, which can only be acquired by 
cultivated habit, has a great advantage over a fellow- 
scholar who, though perhaps of greater ability, has to 
contend against the multiform innovations of casual 
thoughts. 

Parents are apt to attribute the breakdown of the 
health to educational over- pressure, but the fault lies 
much more often in the want of suitable education. 
Subjects are crammed into a child's head for which he 
has no actual capacity. If it is true of normal children, 
it is still more true of neurotic children that they require 
individual training as much as possible. 

Besides the intellectual gifts, the characters and dis- 
positions of children require to be carefully studied. 
Some are bold, others timid ; some frank, others re- 
served ; some rash, others cautious ; some forward, 
others retiring ; some active, others slow ; and so on, 



154 PREVENTION AND TREATMENT 

each requiring special treatment. For many children of 
a nervous temperament, habits of system, order, punctu- 
ality, temperance, self-reliance, perseverance, and self- 
control may be their salvation in after-life. They 
require such moral education and character organisation 
as will fit them to deal with the practical affairs of life, 
and enable them to do well when launched upon the 
business of the world. 

It is of the highest importance that timidity should 
not gain possession of the child. A nervous child should 
early be accustomed to have confidence in himself. For 
this purpose all about him must encourage him and 
receive with kindliness whatever he does or says. 

Excessive emotionalism is a defect common to the 
greater number of children sprung from a neuropathic 
stock, and its development must at all costs be repressed. 

Bad temper is frequent in neuropaths and unbalanced 
minds, and is very often the result of faulty education. 
The child who is overwhelmed with incessant reproaches, 
or who is thwarted uselessly and on all occasions, retires 
within himself and takes to brooding over his woes and 
disappointments ; little by little he accustoms himself 
to melancholy, and later on he will be more inclined than 
others to pessimism, moral depression, and discourage- 
ment. 

If the child grows up fairly normally, there comes a 
time when a profession will have to be chosen for him. 
Taking to the wrong profession or sphere in life may 
absolutely change the life, so that unsoundness of mind 
may result. A man always runs more risk if he spends 
his life doing uncongenial work, especially if he has an 
innate craving for something else. A square man in a 
round hole is much more likely to come to grief than one 
whose occupation fits his capacity. When we have to 
deal with a neurotic girl or young man inheriting in- 
sanity, it will be of the utmost importance that the career 
chosen should be one fitted to mental constitution, and 
that everything about them should be equally studied 
and regulated with the view of constantly warding off 
the threatened evil. 

Among the educated and richer classes the cry of, 
" What shall we do with our sons and daughters ? " is 



MENTAL DISCIPLINE 155 

an urgent one. The great considerations which should 
help the doctor and the parent in choosing an occupation 
for the young are health, defects, aptitudes, special 
leanings, opportunities, powers of resistance, tendencies 
to special risks and temptations, and special mental, 
moral, or bodily strong or weak points. 

As regards education of the children of the poor, I 
would say, " Find out what each child is capable of 
doing — that is to say, his actual aptitudes ; teach him to 
succeed in these, and then you give him a means of 
livelihood.' ' If only our educators would remember that 
skilled labour and not general education is what is 
valuable ! The various professions and all the so-called 
higher callings are invaded by a mass of young people 
who imagine they possess a faculty on the strength of 
what is called a " liberal education," which means that 
they have simply been " crammed " up to pass a series of 
examinations. In consequence, every avenue of em- 
ployment that is not mechanical is overcrowded, and 
wages for intellectual labour are at their lowest ebb. It 
may be said with truth that a man who has left to him 
a coster's barrow and a good pitch has more wherewith 
to gain a living and a place in the world than any univer- 
sity education can give him. The hardships of the born 
proletarian are small compared to the sufferings of those 
whose artificial education has rendered them ornamental 
rather than useful, and who therefore, when deprived 
through misfortune — which may happen to any of us — 
of the means of independence, are quite unfitted to take 
part in the struggle for life. In this struggle it is not 
merely the morally or physically unfit that go down, it 
is rather those who are morally refined and intellectually 
superior if they have learned nothing that will gain them 
remunerative employment. It is the victims of artificial 
education Who suffer. 

As in regard to modes of education, so in the selection 
of occupations for life the doctor may very well be con- 
sulted. In a book on Scientific Phrenology I published 
some years ago I have tried to lay down in a systematic 
way the points that should guide us in determining the 
character and dispositions of a child and the selection of 
a suitable occupation* 



156 PREVENTION AND TREATMENT 

I am well aware that science has not reached that 
point yet when We have definite indications to guide us 
in every case ; but how much more effectively the world's 
work would be done, how many wasted lives would be 
saved, and how much unhappiness would be avoided if 
we could put every young man and woman into the 
groove for which nature has fitted them. Those who are 
in possession of real genius would not, as frequently 
happens now, be obliged to pine away their lives in a 
garret, and men would no longer be put to the learned 
professions who are scarcely fitted for driving a plough 
or scraping on a fiddle. 

It is singular how few have the fortune to be put, at 
the outset of life, into the path wherein their genius lies. 
This is a true and most lamentable fact, but we cannot 
consider it by any means remarkable under present cir- 
cumstances. The general public have scarcely any 
means of judging of the talents and dispositions of 
the rising generation until they are developed by time ; 
but then, alas ! the knowledge comes too late, as the 
fate of the parties, in most instances, has been irre- 
vocably fixed. It would be impossible to overrate 
the pleasures and advantages which would arise from 
having the right men invariably in the right place. 

What has been said with reference to the training of 
children to self-control applies equally to the adult. 
Many persons have naturally a very limited supply of this 
power, or it has not been cultivated in them in youth, so 
that it takes a small occasion for them to lose it. Ex- 
haustion, mental or bodily illness, or any bodily weak- 
ness, has the effect on such people of paralysing their 
power of self-control. They will be angels or demons 
just as they are fresh or tired. Self-control implies 
command of temper, command of feeling, coolness of 
judgment, and the power to restrain the imagination and 
to curb the will. 

What is insanity but a condition in which our thoughts 
and feelings are no longer under voluntary control ? It 
is the presence or absence of the power of self-control 
which constitutes the great distinction between sanity 
and insanity. 

The insane have fixed ideas and habits which they 



MENTAL DISCIPLINE 157 

have not the power, in themselves, to change, and later 
on, as the disease progresses, have not the desire to change. 
To overcome obsessions and delusional beliefs by vo- 
litional effort, it is far better to make that effort in the 
direction of thinking of other subjects or of doing some 
work that has nothing to do with the obsession, than to 
" reason it out " and make efforts of will directly in the 
teeth of it. Evade it rather than stand up to it should 
be the rule in most cases. Turn into a side road rather 
than meet your enemy in the face of his line of com- 
munication. Switch your mind on to a loop line and let 
your foe pass by. Whistling to keep up courage is no 
mere figure of speech. 

We want to learn in our youth to concentrate at will, 
to switch our brain on and off in a particular subject, as 
one switches electricity on and off in a particular room. 

What training can do can be seen by the different 
effects the same conditions produce on different indivi- 
duals. One is cheerful and contented under circumstances 
which depress and discourage his neighbours. One sees 
only blemishes and defects in the things about him, 
whilst another sees in these same things the beauties they 
possess and the purposes they serve. One regards 
everything in its relation to himself alone, whilst another 
unselfishly considers its bearing on the general weal. 

Unrestrained doubts tend to make the judgment im- 
pervious to evidence. Discontent likewise deprives even 
the luxuries of life of their satisfying power, and makes 
its votaries in the palace more dissatisfied with their 
wealth than the poor man is with his pittance. 

Closely allied to indulgence, in its effect, is the habit 
of brooding over unwholesome currents of thought. A 
sense of injury magnified by frequent reflection and 
indulgence will generally lead to ideas of revenge, and 
thus evil begets evil, and is multiplied. Many a suicide 
owes the loss of his life and its priceless, irretrievable 
opportunities to the indulged contemplation of the 
idea and the consequent increase of its force and weaken- 
ing of that control which could have saved him from so 
miserable a fate. 

Mental discipline gives force and efficiency to the 
mental powers and strength to character. The lack of 



158 PREVENTION AND TREATMENT 

it weakens the intellect. The dissipating effect of a 
listless habit extends to every department of mental 
action. Listlessness does not imply a want of thought, 
but of its useful and effective application. Uncontrolled 
and wandering thought is generally led into unwholesome 
currents ; it is often engrossed by captivating ideas. 

The ruling motive of the strong-minded man who 
maintains a mastery over the direction of his mental 
faculties is determined by the principles he has imbibed 
and not by the feeling of the moment. He is a reasonable 
being, not only as possessing the full measure of reason- 
ing powers, but because they furnish the actuating 
motives which determine his judgment and regulate his 
conduct, freed from the enslaving influence of adventi- 
tious circumstances. 

In the stress of modern civilisation, the man who 
has no unity in his scheme of life and is racked with 
doubts, the man who frets over trifles and tries with his 
disjointed and vague philosophy to solve every little 
point as it arises, whose only measure or ultimate sanction 
for action is the impulse of the moment — that man is at 
the mercy of circumstances, his nervous energy is readily 
exhausted, and he is liable at any time to fall a victim 
to neurasthenia, hypochondriasis, or melancholia, if not 
to vice and its attendant evils. 

In acquiring mental discipline the cultivation of a 
hopeful spirit is of special importance. Pessimism as a 
working principle of life is utterly bad from the point of 
view of mental stability. Human nature, as a general 
rule, absolutely needs for its continual mental health the 
support of a reasonable optimism. I do not wish to 
talk as though all men had it in their power to be opti- 
mistic or pessimistic, just as they liked — that is not so. 
Those conditions of feelings, to a large extent, come by 
temperament ; but most men also have some choice in 
that, as in other things of life. The cultivation of a 
thankful spirit and a reasonable humility, and the de- 
termination not to let the pin-pricks of life upset them, 
would do much to prevent men and women getting on 
the slide which ultimately leads to the quick descent 
into unsoundness of mind. 

The difference between the grave and the gay, the 



MENTAL DISCIPLINE 159 

cheerful and the gloomy, the hopeful and the desponding, 
between the thankful and the discontented, the observant 
and the unheeding, is due in large measure to acquired 
habits of thought. 

With many people it is idleness which leads to mental 
disorder. They have nothing to distract them from 
perpetual self-contemplation. While some men have 
too much work and mind-toil, others have too little, 
and lead an idle, aimless life, which either tends to bad 
and solitary habits and perhaps to drink, or fosters a 
habit of continual self-introspection and perpetual com- 
plaint that they are misunderstood. They may be 
independent, and have no longer need to work for a 
living ; but such persons should be encouraged to take 
up some pursuit or hobby, to study some branch of 
science or art. Every such pursuit is an assistance to 
the neurotic and predisposed individual, and great will 
be the benefit gained from it. Not only ought the idle 
to have such occupation, but the busy and hard -worked 
man should have beyond his everyday task some amuse- 
ment, pursuit, or hobby to which he can turn as a relief 
from his daily round of business and find therein food 
and rest for his mind. Often busy men break down, 
simply because, apart from their business, they have 
no thought, no occupation, no mental amusement. 

The exercise of the brain in intellectual pursuits keeps 
that organ, and with it the entire body, young. It is 
highly instructive to observe the longevity in men of 
high intelligence. Such instances are furnished chiefly 
by those callings which require the continued exercise 
of the intellectual faculties upon comparatively new 
matter or upon new combinations of familiar data. 

For the old man, work or occupation of some kind is 
a necessity. The peevishness, irritability, and aimless- 
ness of old age would be impossible if the old would 
remember that mental health depends on the possession 
of a store of permanent and valuable interests. These 
interests should be gained earlier in life, so that, when 
the main work of one's calling must be resigned, the 
mind may still retain a measure of freshness and vigour 
and the nervous system a degree of balance and poise. 



CHAPTER XII 

THE PRIVATE TREATMENT OF INSANE 
PSYCHO-THERAPEUTIC AND HYGIENIC MEASURES 

If moral education and the teaching of self-control are 
so important in childhood as a preventative of insanity, 
it naturally suggests itself to adopt the same method 
in those who have become insane, who have lost control 
over their thoughts and feelings, and re-educate them. 
This is the business of the psycho-therapist, and no 
physician can claim to treat lunacy nowadays who is 
not an expert in psycho- therapeutics. He may be an 
admirable custodian, but he gets no insight into the 
working of the patient's mind, and is unable to exert 
any influence in repairing the disordered functional 
activity. 

We give the truest help to our patients when we aid 
them to get their mental activities adjusted on normal 
lines. In order to do this, we must appreciate the under- 
currents in their lives, provide proper food for their 
normal instincts, and so guard against perversions, re- 
lieve tension and anxiety, soothe excitement, allay fear, 
and train to good and useful habits. 

Every psycho-therapeutic procedure, of whatever 
sort, has in view this definite end : to bring about a 
readjustment, some sought-for and desirable reorgani- 
sation of the individual in respect of his inner and outer 
experience ; to assist him as well as may be in his efforts, 
hitherto frustrated, toward the consummation of a more 
harmonious adaptation to his social and physical environ- 
ment, — in a word, to place at his disposal those principles 
of modern psychology which, rightly used, will not im- 
probably facilitate and further his psychic re-education. 

1 60 



PRIVATE TREATMENT OF INSANE 161 

In order to treat the incipient stage of insanity, an 
intimate study of the temperament, character, and habits 
of each patient is necessary, as well as the circumstances 
of life which have brought out the mental disorder. It 
is not sufficient to consider the organism only as a 
physiological machine liable to derangement by subtle 
toxic matters ; it is necessary to study the patient also 
as an individual in a social organisation. 

The way we proceed is by first trying to discover any 
nutritive, organic, or functional basis for the patient's 
disorder, and by removal of the cause, as far as possible, 
we endeavour to put the patient on the best physical 
basis. Most patients have been worrying so much over 
their disorder, that if we can find no other physical sign, 
we may be sure they suffer from an exhaustion of nervous 
force, which we must remedy before we can hope to 
exercise any influence by talking to them. 

The patient having gained in physical health, has 
also gained in confidence, and our advice makes more 
impression. We must now use mental influences to re- 
educate the patient and to teach him self-control. Need- 
less to say that even with uneducated and poor patients 
great tact, common sense, and sympathy, besides a 
thorough insight into his character, are necessary to 
secure any good results. 

In a book on Hypnotism and Suggestion which I 
published two years ago, I described fully the different 
methods that I found successful in the psychic treatment 
of the insane ; but the title of the book gave many people 
the impression that the business of psycho-therapy 
consists, for the most part, in the use of suggestion in 
hypnosis. There is a modicum of truth, of course, in 
this, but to wholly adopt such an opinion is to take a 
very narrow view of the subject, for it does but add 
yet another example to the already long list of means 
mistaken for ends. Like the artist who uses his pig- 
ments and brushes, now after one fashion, now after 
another, to create different effects upon his canvas, the 
psycho-therapist, working on a more intangible, though 
vastly more plastic medium, utilises his diverse methods 
to work the desired effects upon personality. These 
effects it should be remembered are, and of necessity 
ii 



162 PREVENTION AND TREATMENT 

must be, various kinds of psychic re-education, since it 
must be obvious that no physician hypnotises for the 
mere sake of hypnotising, nor does he suggest or per- 
suade for the mere sake of suggesting or persuading. 

The moral or psychic treatment of mental disorders 
comprises the whole range of methods and devices that 
can affect the patient's condition otherwise than through 
the ordinary medicinal and mechanical means employed. 

Every case is a study by itself, and the measures taken 
should be adapted to its special needs. No one has 
better reason to make a study of character than the 
physician in charge of the insane, and his conduct toward 
them will be modified, advantageously or otherwise, 
according to his skill in estimating human nature and 
individual peculiarities as they appear in persons suffering 
from diseases of the mind. If it is possible, as it generally 
is, to treat the patient as a sick man, realising his own 
conditions and wishing to co-operate in the measures 
taken for his relief, it is best to do so ; the more nearly 
we can treat him as a rational being, the better, as a rule, 
we succeed with him. 

Re-education is the summum bonum of psycho-therapy 
of the early stages of insanity, especially borderland cases. 
If it is true that physical ills require physical remedies, 
ethical and spiritual ills require corresponding remedies. 
The kinds of re-education required by individual patients 
will differ widely. Whereas the simple explanation of 
the true meaning of a troublesome symptom or group of 
symptoms will be amply sufficient for one, for another 
it may be necessary to set about what practically amounts 
to a complete mental and moral readjustment. Hypnosis, 
suggestion, psycho-analysis, may all be necessary to 
our purpose. This it is that often makes psycho -therapy 
take up so much time. But in reality nothing less will 
suffice if the work is to be thoroughly done. 

The more closely we study nervous people, the more 
attentively we seek to penetrate beneath the mask of 
convention that conceals them, the more surely we are 
impelled to the conclusion that, in very large part, the 
acute suffering as well as the chronic misery which goes 
by the name of nervousness is ultimately traceable to 
faulty education, taking education in its broadest and 



PRIVATE TREATMENT OF INSANE 163 

truest sense. And if bad education, whose outward 
manifestation is many times called nervous disease, has 
led to contradictions and frustrations in thought, in con- 
duct, and in feeling, right education may at least help 
to restore some measure of harmony. To remove the 
present conflict, but also what is of equal — indeed, of 
greater- — importance, to prevent the occurrence of 
future conflicts, is the business of psycho-therapy. 

To acquaint ourselves with the mind and character 
of the patient is our preliminary duty. The best 
method is undoubtedly to encourage the patient to 
tell his story in his own way, with just so much of 
direction from the physician as will prevent the intro- 
duction of too many irrelevancies and trivialities in 
detail. In this way one gets hold of the raw material 
upon which psycho-therapy has to operate, and at the 
same time receives some valuable sidelights upon the 
relative emphasis that things have assumed in the patient's 
mind. Furthermore, the sympathetic attention which 
the physician lends to this initial confession is sure to be 
rewarded in the future with confidences more intimate 
and important. 

A very limited experience will suffice to impress 
upon the psycho-therapist that he has in the main to deal 
with two separate sets of phenomena ; firstly, the symp- 
toms in so far as they are directly present to the patient's 
consciousness ; and secondly, the interpretation which 
the patient inevitably places upon these symptoms. 

Fear, and its offspring — introspection — are the evil 
genii of nervous people. It is not the loss of memory in 
itself, but the approaching insanity which they believe 
it to announce, of which they are afraid. Whatever the 
nature of the happening, something has gone amiss. 
Perhaps our patient belongs to the poor. If so, his 
nervous state may have been induced by the fierce struggle 
for mere existence and the everlasting labour to earn 
sufficient bread to feed himself, his wife, and his children ; 
or his habits may not have been of the best, and he is 
now reaping the harvest whose seeds were sown many 
years ago. In the higher social levels we meet with 
the anxieties, disappointments, and sorrows that follow 
upon ambitions frustrated, ideals shattered, hopes and 



164 PREVENTION AND TREATMENT 

wishes that have come to naught. In every walk of life 
are the disasters that accompany the relations of the 
sexes. But whatever the nature of the difficulty may 
be, whether the outcome of emotional shock, of selfish- 
ness, indolence, over-activity, misfortune, or fault, the 
result in its final analysis is much the same — depression 
and weariness of spirit. 

It will do little good to tell this type of patient that 
he should not worry ; he knows as much himself, and if 
he does not, his relatives or his friends have told him 
so, long before he has reached the physician. They have 
also told him, in a spirit of genuine sympathy, that he 
should cease to think so much about himself, or that he 
ought to take a rest, or become interested in some hobby 
or out-of-door sports. Perhaps they have even lent him 
books, which he has read with hopeful diligence, about 
the value of optimism and cheerfulness and self-control, 
with the well-meaning hints as to the best methods of 
cultivating these estimable qualities. But in the end it 
all comes to nothing, and why ? Because it is merely 
touching the fringe of the problem. 

It has been said that it is useless to attempt to con- 
vince a lunatic that his erroneous notions are not true. 
This is correct when serious structural lesions exist in 
the brain. The false intellectual conception is then a 
fixed result of the altered brain-tissue, and is just as 
direct a consequence of cerebral action as is a natural 
thought from a healthy brain. Delusions are symptoms 
due to brain disease, and depend upon and disappear 
with that disease ; therefore discussion and argument 
are without avail, and only serve to irritate the patient. 
It is best to let him talk while we listen, and then 
change the conversation. It is better to remain passive 
before them, to simply ignore them, to lead the con- 
versation to another subject, and avoid everything that 
might recall them to the patient. The patient should 
be isolated as much as possible with his own delusions. 
It would be an error to fall in with the delusion and 
thus strengthen it. 

Still, we know that in health it is sometimes possible 
by argument to counteract the most firmly rooted 
ideas ; it is, perhaps, yet easier to do this by the 



PRIVATE TREATMENT OF INSANE 165 

aid of certain of the pleasurable emotions. And there 
appears to be no reason why the like result may not 
occasionally be produced by arguments addressed to 
a person in the early stages of insanity, and by bringing 
into action those feelings which spring from kindness. 
We know, in fact, that this end is at times accomplished, 
and that, by never for one instant admitting the truth 
of an insane delusion, and at suitable times — not ob- 
trusively, but when occasion offers — urging such argu- 
ments against it as would be convincing to persons of 
sound minds, the patient comes at last to see the falsity 
of his ideas, and to laugh at them himself. Little by 
little he loses faith in his perverted reason, and though 
he may take up another delusion, the last is held with 
much less tenacity than the first. 

The patient may have been sent travelling to get rid 
of him for a time, or to avoid certification, or as a remedial 
measure in the hope that it may do him good ; but on 
board of a ship the circumstances are not such as we 
should prima facie expect to be very beneficial to a case 
of incipient insanity, especially to a case of mental de- 
pression, and it is for such cases that this course is usually 
advised. Life on board ship is in itself — by its monotony 
and want of interest — depressing to many travellers, and 
it is rarely that a ship's doctor has had any more ex- 
perience of insanity than other general practitioners. 
We see frequent evidences of the non-success of this mode 
of treatment in the newspaper paragraphs, which chronicle 
the accidents of persons when taking sea voyages for 
their health. 

Discouraged, weary, pessimistic, the patient comes to 
the psycho -therapist asking, though he does not know it, 
for a practicable philosophy of life. His own has broken 
down, or else he never had anything worth the name, and 
never really felt the need of it until the present crisis 
brought him to the realisation that such a thing is in- 
dispensable. 

Psycho-therapeutics is the most effective weapon at 
our disposal, provided, as already pointed out, that the 
exhaustion and general debility, which are generally 
associated with mental affections, as well as their bodily 
ailments, are duly recognised and attended to, Mental 



166 PREVENTION AND TREATMENT 

hygiene presupposes hygienic bodily conditions — a sound 
mind in a sound body. The preliminary step then in 
mental hygiene is to secure, later to maintain, physical 
health. The contrasting states of mind, optimism and 
pessimism, are largely the result of bodily conditions. 
Fatigue can cause sadness, ideas of negation, and of 
persecution. Take, for instance, that common form of 
insanity, melancholia, our first object must be to put 
the patient in a fit physical state, and then we can break 
up the monopoly of grief and fear which have obtained 
possession of his mind. It is wonderful how sometimes 
a single impression made upon the mind by means of 
suggestion, a single hopeful idea introduced into it, may 
suddenly change the whole current of feeling and divert 
it from a morbid into a healthy channel. If we can once 
fix the attention upon any belief or idea of happiness 
which is capable of attainment, we have made much way 
towards recovery. If we can inspire by our assurance 
any uncertain glimmering hope of restoration, we have 
ministered powerfully to composure and serenity of mind. 

Thus it is that the words and bearing of a physician 
are sometimes more consoling and healing than the 
medicines which he prescribes. If, however, confidence 
cannot be communicated, attention can at least be di- 
verted. Novel impressions may be made to attract it. 

Many borderland cases can be treated in this manner. 
Hundreds of people with hallucinations and delusions are 
uncertified and lead fairly natural lives. They are 
classified as eccentrics, and can often conceal their mental 
defects from the unskilled. As long as their actions, the 
outcome of these delusions, are not of such a nature as to 
be a source of danger to themselves or others, the State 
does not interfere with them. For the borderland 
delusional case, corrections of bad habits, employment, 
change of mode of life, scene, and surroundings are the 
desiderata. 

Special suggestions may be made either in the waking 
state, simple psycho-therapeutics, or in suitable cases 
in light sleep — i.e. hypnotism. Deep sleep is not neces- 
sary, nor desirable, but simply a passive subjective 
condition. We can thereby produce rest to over-active 
parts of the brain, and can strengthen the volitional 



PRIVATE TREATMENT OF INSANE 167 

control which the patient exercises over his thoughts and 
feelings. Hypnotism thus applied by trained medical 
men is free from danger, sensationalism, and quackery, 
and is quite different from the notions many people have 
of it. Some physicians fail in trying to use this treat- 
ment, either because they are not trained for it, or they 
cannot judge the suitability and suggestibility of the 
patient for it, or give the proper suggestions in the right 
manner. Others again, when using psycho-therapy, 
ignore the physical needs of the organism, which should 
be first attended to. 

Hypnotism in the treatment of the insane has not 
had a fair trial yet. In my opinion, hypnotism judiciously 
employed in the early stages of insanity will effect a cure 
in many cases. It is best employed on such patients as 
are aware that they are sick, and who lend themselves 
to it of their own will. 

Hypnotism is a mysterious power of which we still 
know very little. To show what miracles can be per- 
formed by it, I quote herewith only one experience, to 
the accuracy of which both the local medical attendant, 
the patient herself, and her relatives have testified. 
An account of it was published in The Medical Press, 
January 3, 1912. 

" The patient, a girl, twenty-two years old, was sent 
to me on November 13 by her medical attendant. Ac- 
cording to the history furnished by him, the girl has 
had chorea, with heart complications (endocarditis), since 
she was ten years of age. At fifteen years of age 
she had acute rheumatism, and was in bed for some 
weeks. At nineteen she had an attack of appendicitis 
which recurred, until in May last year the appendix was 
removed. The year previously, May 1910, she took to 
the use of a bath-chair, apparently owing to an inability 
to walk without having pains and getting prostrated. 
The patient suffered besides from insomnia owing to night 
terrors, her screams rousing the people in adjoining 
rooms. Mentally, she was in a very depressed condition 
and talked little, nor would she smile. She was still 
using the bath-chair when she was brought to me. Her 
personal appearance was that of an invalid in a very 



168 PREVENTION AND TREATMENT 

feeble state, her body almost rolled up and her head 
turned to the right shoulder, as if suffering from torti- 
collis. 

" On her first visit I merely tested the suggestibility 
of the patient, and reported to her doctor that I had no 
doubt that I should be able to cure her. On her next 
visit, November 16, I attempted to hypnotise her, and 
was partially successful, and considerable improvement 
followed. On November 24 she came again, and this 
time fell under my influence within a few minutes. She 
did not actually fall asleep, but she could not open her 
eyes, and was unable to move her limbs. I suggested 
that all the muscles would resume their normal position, 
that srie would be free from pain, sleep well at night 
undisturbed by dreams and visions, and would be cheerful 
and talk freely. On rousing the patient, her outward 
appearance had completely changed. She held herself 
erect, seemed happy and well. What happened after- 
wards is best told by quoting her sister's letter to me, 
dated November 29 : 

" ' After leaving your house on Friday we walked along 
Oxford Street, through the lower departments of Sel- 
f ridge's, on to Marble Arch, and across the Park to St. 
George's Hospital, where we took an omnibus for home ; 
that, for a girl who has scarcely walked a yard and has 
been wheeled about in a bath-chair since two years ago 
last May, is little less than a miracle. She is sleeping 
splendidly and naturally. All her terrible night fears 
have ceased to trouble her — and us, as her screams used 
to rouse us all at times. Her new cheery outlook on 
things in general would be almost laughable, if we were 
not so intensely thankful. It seems almost impossible 
— a fortnight ago an apparently incurable invalid, again 
and again unconscious in her bath-chair in the streets, 
and now to-day, and every day since your treatment 
began, a normal, cheerful girl who is able to move about 
and speak, and whom it is a pleasure to be with.' 

" On December 1 the patient called again, perfectly 
well, but she drew my attention to the fact that she had 
been suffering all along from constipation and amenor- 
rhoea, and inquired whether I could cure also these 
complaints by the same method. When she was hypno- 



PRIVATE TREATMENT OF INSANE 169 

tised, I suggested to the patient that on being roused her 
bowels would act, and after that every morning regularly, 
and that she should have her period within twenty-four 
hours. The patient had a good motion directly she was 
awakened, and as regards subsequent events, I can quote 
her sister's words, as per letter of December 3 : 

" ' You scarcely need telling, I suppose, that once 
more your suggestions have taken wonderful effect in 
the case of my sister. Her bowels have acted naturally 
yesterday morning and this morning, and her period 
arrived yesterday afternoon at 2.20. I cease to wonder 
at anything now ! Her sleep, speech, cheerfulness, erect 
carriage, proper method of breathing, interest in life — 
all restored ; freedom given from pains everywhere, 
dread Of being again ill taken away, and now action of 
the bowels and period produced.' " 

The patient has kept well, up to date. 

By the application of psycho-therapeutics I have 
seen hallucinations and delusions disappear, and suicidal 
tendencies given up ; I have treated maniacal and 
melancholic states successfully, as well as kleptomania, 
religious mania, alcoholic mania, and morphia mania, 
delusions of persecution, hysterical psychoses, perverse 
sexual habits, doubting and querulous mania, and other 
symptoms of a deranged mind. The cases of cure have 
been fully described in my book on Hypnotism and 
Suggestion. 

Hypnotism may be used to overcome the morbid 
resistance of patients. Patients often refuse to do what 
is necessary for their welfare, but by hypnotising them 
they can be made to do what is desired. In cases of 
excitement and violence, instead of mechanical, physical, 
or chemical restraint, hypnotism may be used as a form 
of mental restraint. 

Hypnotism will succeed in intractable cases of in- 
somnia where drugs have not succeeded well. Hypnotic 
sleep, being more closely allied to healthy sleep than is 
drugged sleep, must be of great service where the brain 
nutrition was already bad, without the additional de- 
pression of sedative drugs. It will be of direct thera- 
peutic value in preventing an outbreak of excitement 



170 PREVENTION AND TREATMENT 

from passing into mania in a brain which is in a highly 
unstable condition. An impulsive outbreak in an epilep- 
tic, an hysterical emotional attack, or a fit of excitement 
in a recurrent or adolescent case, might all pass into 
mania ; but if the patient were quieted and sent to sleep 
for a few hours, this danger might be averted. 

The failure of sleep is a symptom of the highest im- 
portance. By remedying this, more can be done to- 
wards warding off, and for the treatment of insanity, 
than by any other measure. Again and again it happens 
that prolonged sleep will dissipate the fears and suspicions, 
allay the excitement and irritability, and bring the 
sufferer back to his sane mind. 

The insane are usually not devoid of all reason. Many 
of them have a good deal of their logic and commonsense 
preserved, which can be utilised by the operator. At a 
suitable opportunity we may succeed in hypnotising 
them and get the morbid mental activity to rest. If we 
can do no better, we can send them into a sound refreshing 
sleep for such length of time as is deemed beneficial. 
It is strange that this necessity of brain-rest has hitherto 
received little or no attention. The physician knows 
well that in kidney disease he must rest the kidneys, and 
allow their functions to be performed by other parts 
of the body ; he knows that a diseased stomach must 
receive no food — at least, no solid food ; but a mental 
patient may indulge in his morbid thoughts as much as 
he pleases, and as a consequence they become more and 
more fixed. 

The poor results in the treatment of insanity by 
hypnotism achieved by some authorities I hold to be 
due to the fact that they have not selected proper cases 
and, generally speaking, not under conditions essential 
to success. Thus, frequently sufficient time is not given 
to the attempted induction of hypnosis ; the experiment 
is not repeated often enough, and, after hypnosis is 
obtained, prolonged sleep is rarely employed. It is 
admitted, of course, that the insane are much more diffi- 
cult to hypnotise than the sane. Melancholies become 
hypnotised with difficulty, but cases of simple mania 
with greater facility, and very fair success can be obtained 
among the more sensible and reasonable patients if 



PRIVATE TREATMENT OF INSANE 171 

their consent and confidence are gained. The introduc- 
tion of hypnotism does not overturn the established 
modes of treatment, but it is an additional useful 
therapeutic agent. Every physician should have a 
scientific understanding of the effects of mental sug- 
gestion, which throughout all ages has been, and is 
still used, empirically and unconsciously. 

The fundamental necessity in all mental therapy at 
the height of the disease is to place the patient in the 
greatest possible mental quietude. All injurious mental 
influences must be removed. Efforts to distract, amuse, 
or teach at this stage can do only harm. The melan- 
cholic requires peace, because painful impressions are 
excited by all psychic activity, even those that are in 
themselves normally pleasant. The maniac requires 
quietude because his cerebral excitement is otherwise 
intensified. Exhausted patients require repose because 
every mental impression exhausts them still further. 

In the period when the disease changes for better, 
psycho-therapy has again an active part to play. The 
art of the alienist is here displayed in the understanding 
of the individuality of the patient leading up to the 
restoration of the normal mental personality, or at least 
to save all that is possible out of the mental wreck. 

With many patients, at the turning point of their 
disease, positive interference is necessary in order to 
free them from the habits into which they have been 
forced by their mental disease. It is here where mental 
training comes in. 

Occupation of some kind must be insisted upon, and 
the work done should be real. Occupation diverts the 
brain from its pathological activities, and concentrates 
the attention on the work in hand. Every mental 
patient should be made, as far as possible, to occupy 
his mind in some practical manner. Nothing is more 
injurious than allowing him to indulge in his exalted or 
gloomy thoughts uninterruptedly, as he does when left 
to himself. Occupation used for the purpose of bene- 
fiting a patient should gradually and unsuspectingly 
arouse his interest along lines away from himself. This 
is essential, and it is equally necessary that such occu- 
pations should be of a character to attract the attention 



172 PREVENTION AND TREATMENT 

of the patient. No occupation should be of too laborious 
a character, but a degree of physical exertion is won- 
derfully helpful. 

Rest in bed has a calming effect in acute mania. There 
is no doubt that by its suggestion of rest and invalidity, 
and by its physiological effects on the nervous system 
and blood- pressure, it has a distinctly calming influence 
on acute excitement. 

In states of excitement, the prolonged bath at the 
temperature of the body is also a most useful calmative, 
and it has none of the objections alleged against sedative 
drugs. It is a mistake to suppose that it is dangerous 
or has a debilitating effect, as it tends to raise the blood- 
pressure, and in imagining these evils, as some do, they 
are confounding it with a hot bath, which is relaxing 
and distinctly dangerous if prolonged. 

A large part of the excitement witnessed in former days 
was mainly a reaction to the harsh and irritating treat- 
ment the patients then received. The better treatment 
of the insane nowadays has made the cases of acute 
mania of a milder type. 

With proper treatment violence can be avoided, and 
in the newly established clinics on the Continent " padded 
rooms " no longer exist. The disadvantages of such 
isolation, of which one need only mention the unclean- 
liness, destructiveness and violence, are obvious. In- 
deed, I fail to see how any asylum can make any claim 
to call itself a hospital for treatment of mental diseases 
if it confines its troublesome patients in a padded room. 
By this means the patient is certainly shut off from the 
ward, but we no longer know what his real condition is, 
though we listen to his cries or look at him through a 
peep-hole. One can no longer speak of the true " nurs- 
ing " of a patient. I have had patients in my care who, 
in the opinion of medical superintendents and lunacy 
commissioners, were considered as most violent and 
highly dangerous; but I was able to manage them by 
simple means. No doubt precautions are necessary, 
but what can be accomplished in private care should 
be easier still in asylums. In any case padded rooms 
can have no remedial property, and serve only the pur- 
pose of getting rid of troublesome patients, 



PRIVATE TREATMENT OF INSANE 173 

In the front rank of those therapeutic measures that 
are capable of acting indirectly on the patient's mind 
must be also placed electricity in its various modes of 
application. There is no doubt that good results have 
sometimes been obtained from static electricity (baths, 
douches, frictions, etc.) or from the constant current 
or faradisation ; on some occasions the general condition 
of the patient has been sensibly improved, on others 
some conspicuous symptom has disappeared. 

Isolation, withdrawal from the surroundings in which 
his neuropathic state developed, residence in the country, 
or in a special establishment, hydrotherapy, electricity 
— all these therapeutic agents not only influence the 
somatic state of the patient, but in very dissimilar 
ways they also act beneficially on his mental state. 
It may even be affirmed that it is to this moral action 
that they owe a great part of their curative power. 

Amusements, especially those which can be taken in 
the open air, are almost always of service, and a proper 
system of rewards and punishments for good and bad 
conduct is understood by all but the most furious maniacs. 
Kindness and forbearance, supported by firmness, will 
not altogether fail in their influence with even the most 
confirmed and degraded lunatics. Probably the most 
difficult class of patients to manage by moral means is 
that of the reasoning maniacs, and next to them those 
cases of hysterical mania which exhibit marked per- 
versities of character and disposition. But even with 
such people the principles of justice and fair dealing 
will not be lost, and eventually an impression will prob- 
ably be made on subjects incapable of being touched by 
other measures. 

Environment has more to do with one's well-being 
than we are wont to realise. There is a marked difference 
in persons in this respect, but all of us are influenced by 
the rooms in which we live — their heterogeneous arrange- 
ment, the colours that predominate, that harmonise or 
clash with one another, the noise or quiet that prevails, 
the purity or impurity of the air, and the sympathy or 
antagonism of the mental atmosphere. We all act and 
react upon one another, and it is true of every one, even 
of the most self-contained or the most callous, that we 



174 PREVENTION AND TREATMENT 

do our best work in what we feel to be a sympathetic 
environment. Persons with an exaggerated sensibility 
are, of course, much more readily affected by their sur- 
roundings than are others, and all nervous and mental 
invalids come under this head. Many of them require 
to be taken out of themselves, to be drawn into taking 
an interest in the objective rather than in their own 
subjective feelings, and they find unusual pleasure in 
suitable social surroundings. 

It is the false idea that all lunatics are raving maniacs 
that has kept the nursing of the insane at a low level. 
In order to control the patients, only coarser and grosser 
kinds of men could be found to undertake the work. 
With the era of humanitarian conception of treating 
madness there arose a totally new aspect. Now there 
are eight or nine thousand trained nurses in our asylums. 
Most mental doctors are agreed that upon the nurse, 
even more than upon themselves, devolves the re- 
sponsibility of the patient's ultimate recovery ; he or 
she is continually with the patient, has opportunities 
for gentle, persistent influence, and it is evident that 
for this work the very best type of nurse is needed. 
Nurses and patients react upon one another to a sur- 
prising degree and in numberless ways. Quiet, calm, 
systematic and well-controlled conduct on the part of the 
nurses is conducive to the same traits in the patients. 

It is not always easy to obtain good attendants for 
the insane at home. Even trained nurses have not 
always all the qualifications required for the proper care 
of the insane. Besides the mere nursing, the precautions 
in regard to possible attacks of violence, insane impulses 
towards suicide, etc., must be impressed. Nurses should 
be selected, if possible, for their kindly and patient dis- 
position, together with a certain power of control of 
others that can be exercised if needed. When proper 
attendance can be secured, insane patients can be cared 
for outside an institution. Medical control, however, is 
essential. An insane individual is always to some extent 
uncertain as to his conduct, and in many cases explosions 
of active insanity are liable to occur. In other cases 
their habits and tendencies are such as to make it neces- 
sary that some special supervision is given. 



PRIVATE TREATMENT OF INSANE 175 

Some persons have an inborn adaptability by which 
they readily obtain an influence over all with whom they 
come in contact. Others, with the best intentions in the 
world, never succeed in ingratiating themselves with 
those about them. Patience and tact are probably, in 
such cases, as indispensable qualities as can be possessed. 
Without them, all the knowledge that can be acquired 
in a lifetime will be of but little avail. 



CHAPTER XIII 

SURGICAL TREATMENT OF SOME FORMS OF 

INSANITY 

It would be ludicrous to assume that every case of 
insanity can be treated by psycho-therapeutic, hygienic, 
or medical measures. In the opinion of a good many 
modern specialists of that disease, insanity is in a great 
number of cases of toxic origin, and will be cured when 
we have discovered the necessary anti-toxins. That is a 
field of investigation for the pathological laboratory, and 
since we are only at the commencement of the inquiry, 
it is outside the scope of this book to do more than 
mention it. 

There are other causes of insanity, however, of which 
we have had considerable experience, which also cannot 
be treated by such moral measures as we have described, 
but in reference to which surgical treatment must be 
considered. They are all the cases of insanity in which 
there is some physical irritation to the brain, due to 
depressed bone and splinters from the inner table of 
the skull in consequence of injury, osteophytes, thickened 
bone from circumscribed inflammation or adhesion of 
membranes from the same cause, localised haemorrhage, 
foreign bodies within the cranium (bullets), tumours, etc. 

Of course the most frequent lesion which has deter- 
mined the operation has been depressed bone, and the 
other lesions are mainly subsidiary to this, though also 
found in cases where no depression in the bone could 
be felt, where perhaps only a cicatrix or some evidence 
of old contusion existed. It is important to give full 
value to these lesions or secondary affections of the 
inner table, of which no external evidence can be got. 
They can at best be only suspected, but their compara- 

176 



SURGICAL TREATMENT OF INSANITY 177 

tive frequency has been abundantly proved. Splintering 
of the inner table without manifest damage to the outer 
has long been recognised as a fact. Head injuries often 
cause concussion and bruising of the brain, giving rise, 
if not to severe haemorrhage, to minute multiple extra- 
vasations which damage the brain. 

Altogether there are a considerable number of cases 
in which a constant irritant causes mental symptoms, 
and sometimes leads to definite forms of insanity. In 
my book on The Mental Symptoms of Brain Disease 
I published a collection of such cases, some of which 
have been treated surgically and recovered completely. 
Amongst those who were cured in this remarkable manner 
were thirty cases of melancholia, thirty cases of mania 
and homicidal insanity, several cases of delusional in- 
sanity, as well as cases of hypomania, moral insanity, 
general paralysis of insane, and even dementia. 

Just one example may be quoted of one of my own 
cases, published in the Lancet, 1907 : 

' Patient, aged 39, a doctor of medicine, previously 
quite healthy, fell from his cycle onto his head. He did 
not think that he had received any marked injury, and 
did not believe there was any connection between his 
subsequent illness and the accident. There certainly 
were no external signs, but soon after the accident he 
began to suffer from headache so severely that he could 
not go on with his work. He got depressed, anxious 
without sufficient cause, accused himself of all sorts of 
evil deeds without foundation, and made some attempts 
on his life, so that he had to have a companion to watch 
him. He consulted various specialists, who advised 
change of scene ; but travelling did him no good. The 
depression and headache increased, and he also suffered 
temporarily from word-blindness. He consulted the 
author six years after the accident, and was then melan- 
cholic, emotional, readily weeping, and very suicidal. 
The right side of the head pained him much, and there 
was a burning sensation just behind the right parietal 
eminence. Operation was proposed, which Mr. William 
Turner, M.S., F.R.C.S., carried out. Only when the 
head was shaved a scar became visible, which extended 

12 



178 



PREVENTION AND TREATMENT 



from the situation of the angular convolution just behind 
the parietal eminence vertically downwards for about 
two inches. A semi-circular flap was made extending 
from the ear to the occipital protuberance, and the scar, 
which was adherent to the bone, was detached. Two 
trephine openings, one 1 inch and the other y£ inch 
in diameter, were made and connected with one another. 
The bone over the angular convolution was thickened and 
ivory-like, without any evidence of diploe, and the dura 
mater was attached to the bone. The brain bulged into 
the opening made but did not pulsate, notwithstanding 
a strong pulse at the time. On incision of the dura a 
stream of clear fluid escaped. The membrane was found 
thickened, but the brain appeared quite normal. Dura, 
periosteum, and flap were each closed with stitches, 
only a small opening being left for drainage for some 
days. Patient was at once free from pain, and of 
cheerful normal disposition, and has remained so ever 
since/' 



Apparently there is no limit to the time that may 
elapse when surgical treatment may still be successful, 
for amongst the cases published by me — 

Two were cured 3 years after the accident ; 



Five „ 


, 4 


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One was , 


, 6 


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Three were , 


, 8 


>> 3 


Two 


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a > 


Two „ 


, 16 


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One was , 


, 25 


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One „ , 


J 3i 


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While it must be admitted that the cases in which 
surgical interference has been resorted to are still very 
small in number, we may be sure that as our knowledge 
of the localisation of mental functions in the brain be- 
comes more definite, operative treatment will become as 
common in the case of brain disease as it is already in 
disease of other parts of the body. 

Sometimes the brain is injured not at the point struck, 
but the damage is done at a point opposite to it, where 



SURGICAL TREATMENT OF INSANITY 179 

the brain rebounds. Frequently there are local symp- 
toms which assist us in the discovery of the seat of the 
disease and confirm us in our localisation, such as head- 
ache limited to a particular region, pain on deep pressure, 
or one of the recognised sensory centres may be affected, 
or else one of the well-known motor centres in the brain, 
the location of which may support our deduction. It is 
not always easy to locate the centre first attacked if there 
is no outward sign of injury, especially by those not con- 
versant with psychological analysis, hence few operations 
have yet taken place for the relief of symptoms. But 
there can be no doubt that many cases are left uncured 
because we have not the courage to attack them surgi- 
cally. The surgeon has already usurped much of the 
territory of the physician. It seems time that he took 
in hand some of the problems of insanity. For if localised 
injury is always accompanied by the same symptoms, 
which disappear after the operation of trephining, we 
may be sure that when such symptoms arise without the 
history of an accident, the same area is diseased through 
other causes, and we may expect the same relief aftef 
operation. Nowadays there is little danger in operative 
measures, and they can be quickly performed. Unfortu- 
nately the well-known anxiety on the part of the patient's 
friends to assign the utmost importance to an old injury 
causes their evidence in that direction to be held in light 
esteem, hence few medical psychologists have thought of 
the possibility of a surgical cure. It appears strange that 
the connection was not recognised, as, however greatly 
the estimates of the value of head injury as a cause may 
differ, a certain number of cases continually occur in 
which the mental deterioration follows a severe injury 
so directly and so evidently as not to admit of a doubt 
of their true connection. 

The physician who is not acquainted with an analysis 
of the intellect and feelings of man does not know what 
to inquire and look for. Hence it happens that a number 
of cases of injury have been recorded, in which large 
areas of the brain have been destroyed without any 
apparent loss of function. The mental powers — it is 
reported — did not appear weakened. In my opinion, the 
men who record such cases only exhibit their own 



180 PREVENTION AND TREATMENT 

ignorance and want of observation. So long as the 
patient can answer ordinary questions about his food, 
number of his family, his location at the time, and at- 
tends to his bodily wants with some care, he is considered 
not to have lost any mental power ; but to test for mental 
deficiencies, a knowledge of the primary mental powers 
is absolutely necessary. Fifty years ago there was a 
doubt as to the possibility of localisation, but to-day it 
is an accepted doctrine that there is a plurality of centres 
in the brain with definite functions. There can be no 
doubt that injury or disease of a circumscribed portion 
of the brain can cause derangement of the mental power 
which is located there. True, the whole brain may in 
course of time become disorganised, when the patient 
will be completely demented ; but still the disease takes 
a start in some particular locality, which should be 
diagnosed by the physician conversant with the localisa- 
tion of mental functions in the brain. 

By some, only intellectual defects and not changes of 
character are considered as affections of the brain, and 
this accounts for the statement that injuries of the 
brain may be sustained without being accompanied by 
any mental symptom. Surely the assumed integrity of 
the mental faculties in cases where the brain is injured 
or diseased rests on no foundation save ignorance or 
lack of attention on the part of the observer. If it 
were not so, of what good is the brain ? 

There are cases on record in which the memory of 
names, places, objects, numbers, dates, events, faces, 
became lost and a circumscribed lesion was discovered 
post mortem. How often does a clinical clerk inquire for 
such details? Other cases there are on record, very 
numerous indeed, of lesions of the brain, which produced 
very marked emotional changes, from previous cheerful- 
ness to melancholy, from gentle peacefulness to irascibi- 
lity, from love of family to hatred of wife and child. 
Again might it be asked, where is the clinical clerk who 
would notice such changes, and in case he did not notice 
them, would suspect and look for a lesion in the brain ? 

He might believe that the patient was able to manifest 
all his faculties unimpaired, seeing that by the word 
faculties he meant solely the intellectual powers. Does 



SURGICAL TREATMENT OF INSANITY 181 

not the melancholic reason clearly, and the patient with 
a systematised delusion judge correctly, if we only 
grant his premises ? When a man whose character has 
been of a pacific tone, becomes, after having received a 
blow on the head, quarrelsome ; and another whose 
previous inclination has been honest, after a similar 
injury experiences an irresistible impulse to steal ; or 
a man previously of gay bent, after a brain-lesion becomes 
depressed ; or again, a fond mother, after a localised 
meningitis subsequent to ear-disease becomes suspicious 
of her own children, — can we say of these individuals, 
who certainly retained their consciousness, memory, 
judgment, etc., that their wounds had exercised no in- 
fluence upon the manifestation of their mental facul- 
ties ? Of course, not every case of insanity requires a 
surgical operation for its cure. Only those with focal 
lesions can be operated upon. Each case should be 
studied on its individual merit. But there are certain 
cases in which the mental change affects one or more 
definite mental powers, whose localisation in the brain 
is known to us, and when the mischief in the brain is 
sufficiently severe to lead us to suspect pathological 
conditions in the brain, or tissues covering it, and that 
in a circumscribed part only, then a surgical operation 
may become advisable. However old-standing the di- 
sease, a careful investigation of the history of the case 
may lead to the discovery of the focus of the primary 
lesion. 

Roughly speaking, we can already distinguish between 
affections of the anterior and posterior half of the brain. 
When the lesion is limited to the anterior half, the 
patient is generally sanguine and cheerful, he often is 
witty, and feels in excellent health ; while in lesions of the 
posterior half of the head there is usually a sense of 
depression, and the only way the intellectual processes 
suffer is that they are retarded. 

When the frontal lobes are irritated by injury and 
a condition of hypomania is produced, there is in- 
creased activity of the mental processes of perception, 
association, and reproduction. The patient forms numer- 
ous plans and projects, has a rapid flow of ideas, and 
through the stimulation of the speech-centre is loquacious. 



t82 PREVENTION AND TREATMENT 

His talk, at all events in the early stage of disorder, is 
perfectly coherent. The other lobes of the brain being 
unaffected and deprived of the control of the intellect, 
manifestations of the natural feelings and animal spirits 
occur. There is a peculiar hilarity and tendency to jest, 
and there may be actual exaltation. 

When there is destruction of the grey matter of the 
frontal lobes, the processes of judgment and reason 
diminish, there is an inability to fix the attention, to 
follow a continuous train of thought, or to conduct 
intellectual processes, ultimately ending in complete 
dementia. We find, moreover, that in such men the 
struggle between the lower instincts and ethical feelings 
is diminished, or does not exist any longer, and instead 
of a rational man we see a creature given over entirely 
to the satisfaction of his lower desires. Such is the case 
in all forms of lesions of the frontal lobes, and it does 
not occur in lesions of other parts of the brain. 

I have shown in my books that disease of the internal 
ear often spreads to the brain and gives rise to irascible 
insanity and frequently to delusions of persecution. 
When the ear disease has been treated, the insanity 
gives way also. There are no cases more common than 
those in which a mental quality is developed to a degree 
never manifested in health in consequence of a wound. 
Thus I have quoted cases of blows on the temple which 
have caused kleptomania ; blows on the parietal eminence 
followed by excessive fear leading to melancholia ; on 
the vortex of the head followed by religious insanity, 
and so on. And when the source of irritation was re- 
moved, the excited mental power was reduced to normal 
activity. 

A good many operations have been undertaken for 
microcephalic idiocy. It was thought that possibly 
premature ossification of the skull prevented the growth 
of the brain, and if a slip of bone were removed, the brain 
would have room to grow. But this is not so, for if the 
brain wants to grow, the skull grows with it. A micro- 
cephalic brain is not a more or less normal brain of very 
small size, the idiocy resulting from the smallness of the 
parts present, but is always an abnormal and undeveloped 
and, in a great many instances, a diseased brain. Large 



SURGICAL TREATMENT OF INSANITY 183 

areas of it may never be developed, and the cells that 
are present are small and comparatively few in number. 
If a strip of bone be removed from the skull, new normal 
cells will not be produced ; parts that are entirely absent 
cannot be created, and powers that do not exist cannot be 
called into being. The reported improvement after 
this operation is not due to the surgical procedure. 
Many cases have been reported at too early a date, and 
the improvement has not continued. When it has done 
so, it has been due to proper instruction and care and 
not to the operation. 

Although cerebral haemorrhages, due to congestion 
from delayed birth, may account for many of the intra- 
cranial lesions, which are themselves accountable for the 
subsequent arrest of mental growth, yet a definite pro- 
portion are probably due to mechanical injuries directly 
acting through the cranium. But idiocy and minor 
forms of imbecility and moral insanity have been 
asserted undoubtedly to follow the use of instruments 
at birth. The mark of the forceps may be borne 
physically through life, as shown by permanently dis- 
torted heads ; and the depressions in the parietal bones 
occasionally seen may eventually be shown to come 
within the classification of local lesions, within the 
reach of surgical interference and relief. 

The success which has already been won by trephining 
cannot but act as a stimulus to the undertaking of sur- 
gical operations, which hitherto have been to a certain 
extent exploratory, but which, owing to the continually 
accumulating mass of clinical and pathological evidence, 
will be placed on a sounder basis, and will be approached 
with less hesitation. Surgical treatment will be resorted 
to in the future all the more readily, for in most cases it 
is cranial rather than cerebral operation that is needed 
for the relief of insanity, at all events, when caused by 
injury. It is essential that some localising indication of 
a lesion should exist which can readily be reached to 
justify surgical interference. 

Possibly, in doubtful cases of tumour or haemorrhage, 
puncture of the brain may be undertaken as performed 
by several German surgeons. We certainly gather from 
their observations that in suitable cases excellent results 



1 84 PREVENTION AND TREATMENT 

may be obtained both from the diagnostic and the 
therapeutic point of view. 

Recent surgery has proved how tolerant the brain is 
of interference, and it may be fairly prognosticated that 
with a better knowledge of circumscribed lesions the 
application of direct interference will be of service at 
present beyond our dreams. 

If in a case of insanity there is a history of head injury, 
and the site of the injury is indicated by a scar, a de- 
pression of bone, local tenderness, fixed headache, or 
mental agitation, or hallucination, or muscular twitchings, 
can be excited by pressure on the spot, or there are other 
localising symptoms, motor, sensory, or mental, such 
as I have described fully in my book on the Mental 
Symptoms of Brain Disease, operation is not only justified, 
but demanded. But even in cases where there is a 
suspected focal lesion, not necessarily due to head injury, 
but to localised disease, an exploratory cranial operation 
may be undertaken, provided we have definite localising 
symptoms. 

The focal lesion is in one of the centres from which 
radiate influences that affect other parts of the brain. 
The important thing is, if possible, to locate the part of 
the brain which is primarily affected, and then to discuss 
the probability of relief by operation directly over that 
region. 



CHAPTER XIV 

THE TREATMENT OF THE INSANE 

IN PRIVATE CARE, RECEPTION HOUSES, 

AND OBSERVATION CLINICS 

What every case of insanity demands as the primary 
condition for recovery is, separate and individual treat- 
ment and consideration. As we have already explained 
in the Introduction, this is out of the question in an 
asylum, and the Lunacy Laws are such as to make it 
extremely difficult to treat a patient outside the asylum. 
The difficulty arises from the fact that the Lunacy Laws 
were originally framed to prevent those who are not 
insane being treated as if they were ; to prevent those of 
sound mind being deprived of personal liberty in an 
asylum, or elsewhere ; and to ensure proper protection for 
those who are insane, so that they can do no harm and 
that no harm comes to them. To secure these objects 
it is decreed that all persons of unsound mind shall be 
deprived of liberty and certified as " insane/' in order 
to come under the control of the Commissioners in Lunacy. 
The regulations were made extra severe because of a few 
cases of wrongful confinement of sane people, and a few 
cases of ill-treatment of insane persons, by relations. 

Yet any insane person may continue uncertified in his 
own house, and any relative may take him without pay- 
ment. But the moment money is received, be it by a 
relative or stranger, there must be the same certification, 
the same branding as insane, the same visiting, the same 
control, the same restrictions of movement, as if the 
patient were in an asylum. The conditions are identical 
for the most quiet and harmless patients as for the most 
troublesome lunatic. 

It has been widely recognised as an undoubted hard- 

185 



1 86 PREVENTION AND TREATMENT 

ship that the patient who is at the commencement of 
his illness should forthwith be certified as a lunatic. 
The consequences to the individual's career are often 
disastrous as a direct result of this procedure, and a stigma 
forthwith attaches to him which may render him unem- 
ployable in his occupation. It is to this unfortunate 
state of things that we must, to a large extent, attribute 
the too frequent postponement of treatment, so important 
in an early stage, to the day when the patient is hopelessly 
ill and his chances of recovery are enormously reduced. 
Relatives often hide the patient away rather than have 
him certified, and surely this cannot be good for the 
patient ! 

On account too of the almost ridiculous care with 
which the law safeguards personal liberty, and partly 
also because of the reluctance on the part of the patients 
and their relatives to admit insanity and have it pub- 
lished abroad, the treatment in the early stages, which 
would give the greatest prospect of recovery, is rendered 
extremely difficult. On the other hand, it is true that 
the public during many years has become so thoroughly 
imbued with the idea that all cases of insanity are, at 
any rate potentially, dangerous, that there is a prevailing 
conviction that the asylum, and the asylum only, fur- 
nishes the sole means of the treatment and disposal of 
lunatics. Mental disease has excited such terror, re- 
pulsion, and prejudice in the human mind through the 
cruelties formerly perpetrated on the insane, and also 
through the exaggerated description of the " madman ' 
in literature, that the man who is sent to an asylum 
has his prospects and reputation damaged for life. 

The old notion was, and a few specialists hold it still, 
that the best means to promote the recovery of a patient 
who is suffering from any sort of mental derangement 
is to send him to an asylum, and that, so long as he is 
insane,, there is no better place for him. This opinion 
has been urged so persistently, and held so long, that 
it has become a habit of thought, which is deemed by 
some to have the authority of a law of nature. Opinion 
has now, however, changed so much that the question 
which first occurs to the mind is whether it is possible 
to treat the patient out of an asylum. Some authorities 



TREATMENT IN PRIVATE CARE 187 

on mental diseases still insist that ready admission into 
asylums gives better chances of recovery, but this is 
only true in certain cases. All that can be really 
hoped for is that the good care taken of patients may 
shorten the illness. The asylum cannot cure patients 
who would not recover outside just as well, nor can 
the recovery, if it was to be expected from the outset, 
be accelerated more than can be done in different sur- 
roundings. The recovery-rate is no better to-day, 
amongst more hygienic surroundings and increased care 
and comfort, than it was in the days when strait- jackets 
and rough treatment were used in badly furnished asy- 
lums. Some critics even assert that many a case, 
curable in its nature, has become chronic by being placed 
amongst lunatics. 

Certainly I have been instrumental in getting even 
for very bad cases "leave of absence," and achieved 
such improvement in the short time granted to the 
patients, that the Lunacy Commissioners permitted their 
permanent transfer to private care. In cases where 
the patient was considered too dangerous to be allowed 
such leave of absence, I got the relatives to petition for 
a "transfer" to another asylum, and invariably with 
excellent results, although the patients suffered from long- 
standing insanity. It is evident that the change of 
surrounding, though the methods may remain prac- 
tically the same, proved beneficial in these cases. 

Since contact with certified insane persons undoubtedly 
has a demoralising and injurious effect upon many of 
the incipient insane, the question arises how they are 
to be dealt with. Certain cases there are who need such 
control and safe-guarding, or whose mental disorder is 
of such a hopeless nature, that the asylum will be the 
best place for them. Or else they may be so poor that 
the asylum offers them greater luxury and enjoyment 
than could be accorded were they placed alone in a private 
family. But there are many, with ample means — 
patients who make the fortunes of asylum-proprietors — 
whose lives would be infinitely happier did they live 
beyond asylum walls. 

It is not always advisable to keep such patients at 
home, for the influence of the insane upon the other 



1 88 PREVENTION AND TREATMENT 

members of the family must be borne in mind. In a 
very large proportion of cases the outbreak of mental 
disease in any member of the family is, to a certain 
extent, the result of a family taint, which is inherited 
not only by the afflicted individual, but by his near 
relatives. The effect of an insane member of the family 
living in close relationship with the rest, who are them- 
selves somewhat predisposed, and some of them of an 
impressible and receptive age, subject to various influ- 
ences that may affect them, is not in itself a desirable 
one, and may be at times disastrous. Insane patients 
are, as a rule, less easily managed by the members of 
their own family than by others. Their insanity neces- 
sarily makes important changes in their relations with 
other members of the household. They find themselves 
thwarted, opposed, or restrained, where they formerly 
had liberty ; their opinions and wishes, which were 
formerly respected and heeded, now apparently receive 
little consideration ; their authority, which was formerly 
acknowledged without question, is now ignored, and 
they themselves are placed in subjugation. As they 
cannot appreciate the reason for this great change, they 
become irritated by the new relation of things. They 
do not realise that they themselves have changed, and 
hence infer that others have changed in their feelings 
and designs towards them. Not unfrequently these 
changed circumstances are sufficient to convince them 
that their most intimate friends and relations have with- 
out reason become their active enemies. If the patients 
have insane delusions of suspicion, these delusions are 
most likely to be fixed upon their immediate friends and 
relatives, and will be stimulated by their presence. 
Often it is very difficult for the relatives of an insane 
patient to appreciate to what an extent he is insane. 
They see that he reasons correctly and conducts him- 
self well enough in some particulars, and cannot fully 
realise why he should be so unreasonable in other par- 
ticulars ; or, if they do appreciate the facts, they are 
constantly neglecting them in practice. Their great 
anxiety, and the extreme interest they feel in the patient, 
are liable, on the one hand, to render them intolerant of 
his shortcomings, or, on the other, to render them too 



TREATMENT IN PRIVATE CARE 189 

yielding to his many foibles and caprices. Insane 
patients are therefore, as a rule, best managed away from 
their own homes. 

It must also receive consideration that the patient, 
when he isolates himself from his family and withdraws 
from the surroundings in which his insanity developed, 
to individual treatment in single care, preferably amid 
pleasant scenery in the country, he separates himself 
from all excitements, from the cares or even the excesses 
of all kinds to which he was exposed in the social con- 
ditions in which he has hitherto lived ; in short, he thus 
removes from his mind all the factors of over-pressure 
and moral dejection that engendered the neuropathic 
state or helped to keep it up. Such private patients are 
happier, healthier, more tranquil, and enjoy greater 
liberty than those in asylums. I have risked even 
dangerous cases in private care, and never had the 
slightest trouble, knowing what precautions to take. 

It has been said, " Oh ! the patient must not be 
taken out to single care, because in the absence of skilled 
medical treatment, with unskilled nursing, and limited 
supervision, he would be treated with downright cruelty 
and neglect by people ignorant and incompetent." But 
who has ever proposed to do without skilled medical 
treatment, skilled nursing, proper medical and official 
supervision ? By private treatment I mean active 
treatment by a medical man. It is absolutely useless 
to have our patients stowed away in back parlours and 
left there to rot mentally. If this method of treating 
patients privately, with qualified attendants and medical 
supervision, did not work satisfactorily, with perfect 
safety, and without inconvenience, the reporter, the 
telephone, and cheap telegram would have made known 
any failures. If there were any scandalous cases, we 
should hear of them. The only scandal is that the insane 
and feeble-minded do not obtain the necessary treatment 
in the early stages when a cure is still possible. 

Those having charge of patients must be suitable and 
skilled and trained in the care and treatment of the 
insane, otherwise the patients under single care go 
there merely to be housed, and to drift into chronic 
insanity. The nurses having charge of the patients 



190 PREVENTION AND TREATMENT 

should be thoroughly trained in mental work, and should 
be the proper people to take charge of patients, not merely 
with regard to their care, but having in view their re- 
covery also. The medical men who are in attendance 
on these patients must be thoroughly trained in the 
treatment of mental disease, otherwise the patient is 
merely put under care, and the very object we have 
in view — recovery — is lost. 

In Scotland a permissive clause has been in operation 
since 1866, authorising a physician, on his own certificate, 
which is not sent to the Commissioners in Lunacy, but 
is held as a protective instrument by a person who has 
care of the patient, to place a patient whose insanity is 
not confirmed in any private house and under any 
guardian he may choose, for a period not exceeding six 
months, for care and treatment. The advantages of 
this are obvious, and have been frequently pointed out. 

Eighteen to twenty per cent, of all the pauper lunatics 
in Scotland are living in private dwellings throughout 
the country, whereas in England people are still afraid 
of having a lunatic on their premises, considering all 
and sundry persons of unsound mind as dangerous. 

Many patients are quite capable of appreciating the 
amenities of domestic life and the more natural sur- 
roundings, and of enjoying the individuality which they 
retain in private houses and which they cannot have 
while part of the population of a large asylum. Other 
advantages of the private care are privacy and the 
avoidance of publicity, which both rich and poor 
desire alike, and the avoidance of the stigma of treat- 
ment in a lunatic asylum. Nobody suggests the treat- 
ment of all forms of insanity, or, to speak more correctly, 
of all cases of insanity, in private care. It is necessary 
to individualise treatment here, as it is in everything 
else connected with states of mental disease. 

But such treatment is necessarily costly, as it involves 
nursing, possible change of residence, and continuous 
medical attendance. This it is out of the power of the 
poor to obtain. All general hospitals shut their doors 
against persons suspected of insanity on the ground 
that the asylum is the proper place for their treatment. 
The asylums, however, cannot receive cases until the 



TREATMENT IN PRIVATE CARE 191 

symptoms are so far advanced as to constitute " certi- 
fiable " insanity. 

Hence it is proposed to establish Reception Houses 
for the Insane, where patients can be detained until it 
is seen whether it is necessary to send them into an 
asylum, and, if so, to what kind of asylum, or whether 
they can be discharged without having to be put away 
at all. The London County Council is building such a 
place at Denmark Hill to try the plan, having received 
the munificent offer of £30,000 for the erection of such 
a hospital from one of our greatest authorities on Lunacy 
— Dr. Maudsley. 

At present the initial proceedings for the deten- 
tion of a pauper patient devolve upon the Relieving 
Officer, who gives information to a Justice of the Peace 
as to the insanity of an individual whom he has removed 
to the workhouse or infirmary, and in the majority of 
Unions and Parishes it is the Medical Officer of the 
Union who " certifies " the patient (for a regular fee) 
as a lunatic, after which he is transferred to the asylum. 
The removal of the patient to the workhouse is often 
considered by the friends as a great hardship, and com- 
plaints have also been made of too great willingness on 
the part of the Medical Officer to " certify " patients, 
especially senile cases — in fact some consider the ap- 
parent increase in insanity to be partly due to this 
circumstance. 

The advantage of the proposed Receiving Houses will 
be that the alleged lunatic will be taken straight there 
instead of the workhouse, and directly he enters the 
Receiving House he will be under the care of medical 
men who have specialised in mental disease. Thus, 
without doubt, many persons who are at present sent 
from the workhouse to the asylums would not need to 
go to asylums at all, but would improve and recover at 
the Receiving Houses. In connection with these Receiv- 
ing Houses it is proposed to have out-patient depart- 
ments, which will enable persons who need it to obtain 
advice. Thus it is believed that many cases of incipient 
mental disease might be arrested and the need for long 
seclusion in an asylum avoided. Of the necessity of 
such institutions I can speak from experience. 



192 PREVENTION AND TREATMENT 

People who come from a neurotic or insane stock and 
who have children can, and do, seek advice in such an in- 
stitution as to how to prevent weak-mindedness or disease 
in the latter. The medical expert can instruct them in 
many useful precautions. If we are to accomplish any- 
thing in the way of prevention of insanity, it must be 
largely with the children (see Chapter XI) . When people 
are grown up, have their habits formed, and are leading 
an active life — in unsuitable employment and circum- 
stances which they cannot always control — so much can- 
not be done as with the children. Parents can seek 
advice as soon as the child fails to begin to walk or talk 
at the proper age or does not take an interest in its 
environment. The child may have convulsions which 
may lead to epilepsy and imbecility in later life, not 
always due to the difficulties of dentition or accidents 
to the head, as fond parents are apt to believe. Later 
on the child may be highly strung, restless, excitable ; 
he may be backward or precocious, but of ungovernable 
temper ; or he may grow up normally until the age of 
puberty, and then break down and become demented. 
Lastly, he may get through his youth without any 
accident, and become insane only when adult or in 
middle age. Cases of weak-mindedness with criminal 
propensities — " criminals who have committed no 
crime " — would be recognised at an early age before they 
have acquired facility in crime. 

In children of families tainted with insanity we can 
do a great deal towards its prevention. Some of these 
children are of the poorest class, and, if their condition 
were not discovered, they might grow up a menace to 
society, the boys becoming tramps and criminals, and 
the girls becoming mothers of illegitimate children or 
taking to the streets. Incipient cases are at once taken 
in hand and frequently the threatened attack averted, and 
by watching these cases something has been done to guard 
the community against a source of danger. An extra- 
ordinary number of defective children have been brought 
before me, and I believe that such a department can do 
much good in calling attention to these children, whose 
condition otherwise escapes recognition from the lack 
of careful investigation. From a lack of any system 



TREATMENT IN PRIVATE CARE 193 

whereby their condition can be discovered they grow 
up and become a burden to the State. 

If my experience goes for anything, the larger number 
of cases that would be treated in such an institution are 
just those for whom lunatic asylums would be particu- 
larly deleterious — namely, those who display mild forms 
of mental derangement, persons with fixed thoughts and 
obsessions, innocent or dangerous, who are still capable 
of reasoning logically in regard to most of the circum- 
stances presented to their minds, and are still able to 
control their actions, if not all their thoughts and feelings. 
Many cases of neurasthenia, hysteria, and epilepsy 
would be treated, particularly masked epilepsy, when 
actions, innocent or criminal, are performed at regular 
intervals of which the victim has little or no recollec- 
tion, besides a great number of people with uncontrol- 
lable impulses which they are unable to resist though 
apparently conscious and aware of the consequences, 
and though, in the interval between their attacks, full 
of remorse, and behaving in the most exemplary manner. 
I have been consulted about every variety of medico- 
legal case that brings a man before the police-court ; 
frequently I am asked for advice or assistance in cases 
of constant repetition of one kind of offence, such as 
the theft of one kind of article only, people who never 
steal anything else and cannot account for the prefer- 
ence they have for that one article. Sometimes I have 
discovered an arrested development of the brain, some- 
times some malformation, sometimes the marks of some 
head-injury, and, although it is not in my power to save 
such persons from the consequences of their acts, I am 
accumulating the material necessary to support a demand 
for a revision of the law affecting criminals so afflicted. 

Amongst others we also have to treat the chronic 
inebriate, the man who drinks either in excess or to 
whom even a small quantity of alcohol acts as poison 
owing to the weakened brain-resistance. 

Persons who have been insane once or who have just 
got their discharge could consult the physician in refer- 
ence to the progress of their convalescence, and seek 
from him advice as to the best mode of living, so as to 
prevent a recurrence of their disease. 

13 



194 PREVENTION AND TREATMENT 

I can see no reason why every general hospital should 
not be provided with a special out-patient department 
for the diagnosis and treatment of the incipient stages 
of insanity, and even special clinics. 

In Glasgow an experiment in providing wards for the 
hospital treatment of cases of insanity in its earlier 
stages has been carried on during the last six years with 
manifest success, and such a clinic is a feature of a large 
number of university towns on the Continent, especially 
in Germany, Austria, Switzerland, and Italy. Among 
these may be mentioned the clinics of Munich, Greifswald, 
Kiel, Giessen, Berlin, Heidelberg, Vienna, Rome, Florence, 
Genoa, Padua, Turin, etc. In this relation we would like 
to draw attention to the " Temporary Reception Orders " 
under the laws relating to German and Swiss University 
Clinics, on which the director can admit patients at 
sight, without any medical certificate, without any 
stipulation as to the subsequent visitation of the patient 
by any other medical man, and without any special 
proof of urgency. 

In Professor Kraepelin's clinic at Munich they have 
16 doctors and 53 attendants for 120 beds, not counting 
the various lecturers and out-patient physicians. The 
admissions number 1,500 to 2,000 patients per annum. 
Besides Professor Kraepelin's clinical demonstrations for 
ordinary, advanced, and post-graduate students, there 
are lecturers and lectures on the experimental method 
in psychology, on mental cases of medico-legal importance, 
on pathological anatomy, and the histology of the brain 
in insanity, on sero -diagnosis, on clinical psychiatry, 
exhibiting apparatus and instruments, on topographical 
anatomy, and on neurological cases. Every effort is 
being made to investigate insanity from a clinical, patho- 
logical, psychological, and sociological point of view. 
All this in a relatively small capital like Munich. 

I am surprised that England has been so long in adopt- 
ing psychiatrical clinics. 

In Glasgow they have discovered that a considerable 
number of cases which present mental symptoms do not 
require asylum care, but can be successfully treated in 
hospitals. The cases which are sent to the mental 
hospital, which is a separate pavilion of the general 



TREATMENT IN PRIVATE CARE 195 

hospital, are admitted in the same manner as patients are 
admitted to the general hospital — that is to say, they 
are not placed under any form of lunacy certification. 
The period of residence is limited to six weeks. At the 
end of that time the patient must be discharged some- 
where or other. He must either be sent back to his 
friends or discharged as recovered, or he must be certified 
and sent to an asylum or boarded out. 

In the interests of the sufferers, for the furtherance of 
science, and for the spread of knowledge in the medical 
profession, it is essential that in every large city, and 
especially in every university city, there should be 
hospital wards for the treatment of acute insanity, open 
to the public and to medical students, in exactly the same 
way as are the other wards of general hospitals. To 
these wards should be attached an out-patient depart- 
ment to which patients may come for advice. The want 
of such an establishment in every great urban centre in 
the country is an expression of passive cruelty and 
indifference which can only be described as a blot upon 
our much-vaunted civilisation. 

If it became widely known amongst the poorer classes of 
the community that places exist where they can come for 
advice and treatment while they are still conscious of 
their mental disorder, we should have their voluntary 
co-operation, which would do away with half of the 
difficulty we experience in treating the insane to-day. 
One of the chief reasons why they do not come in any 
proportionate number is their dread of being sent to a 
lunatic asylum, the very name of which is a terror to 
them, the remembrance a sort of nightmare, and the 
social consequences of which spell ruin. The very fact 
that such a patient seeks medical advice is a proof that 
morally he is in a favourable state for treatment, whereas 
when the disease has developed, so as to necessitate 
certification, the patient frequently has to be forced to 
submit to treatment. 

Not all patients would be transferred to asylums. 
Directions would be given in the mildest form of cases 
for home-care and home-treatment where the relations 
of the patient could be trusted as companions and care- 
takers or could find responsible persons. Others would 



196 PREVENTION AND TREATMENT 

be treated at the hospital if there was any likelihood of 
a speedy recovery. Others again, and this is a plan that 
I have so far adopted, could be placed in family care in 
cottages in the country. We ought to have a list of 
houses into which persons can be received who are on 
the verge of insanity, whose faculties are not quite up 
to the average, but yet who are capable of being usefully 
employed and made comfortable, when superintended 
by people who have had previous experience in this 
direction. 

Such a scheme would make possible to the poor what 
is at present almost entirely confined to the well-to-do 
classes — viz. the privilege of being " voluntary boarders," 
an arrangement by which numbers of people get well 
without the formality and the odium of certificates. 

The family care of the chronic insane is largely prac- 
tised in certain countries, notably Belgium and Scotland, 
and with success, but in all cases under medical super- 
vision. In this country it has not, as yet, been ex- 
tensively tried. 

I see no reason whatever why in some cases a chronic 
lunatic should not be put in a private house. A con- 
siderable number are capable of some enjoyment in life, 
and many of them are quite harmless and could go 
about with only a moderate amount of supervision. 
The weak-minded cases especially do not want cer- 
tification. They are, as a rule, not dangerous either 
to themselves or others. They only want protection 
against doing foolish things to their own disadvantage 
or being imposed upon by others, and for that purpose 
notification would be all that is needed. 

In Scotland there is provision for the confirmed 
cases who, while still mentally unsound, do not require 
treatment in an asylum. There are many houses in 
Scotland recognised and licensed by the Commissioners 
in Lunacy as suitable places in which such cases can be 
boarded ; the certificate given for such cases testifies that 
the patient, although of unsound mind, is not dangerous 
to himself or others, and does not require treatment in 
an asylum. 

On receiving such a certificate, the Lunacy Commis- 
sioners grant their sanction to the residence of the patient 



TREATMENT IN PRIVATE CARE 197 

in the particular house selected, and the patient may 
remain there for years and years, subject only to a visit 
every three months from his own Medical Attendant or 
from the local practitioner, who must report, in a book 
kept in the house for this purpose, as to the conditions 
and care of the patient and the suitableness of his sur- 
roundings ; and subject also to visitation and inspection 
at any time by the Commissioners, or their deputies, to 
whom the visitation book must be submitted. Thus, 
harmless chronic cases are " boarded out ' in private 
houses. 

That it is not necessary to restrain patients with bolts 
and bars, locks, wards, and high walls, as is done in the 
crowded English asylums, is shown in Belgium, where 
almost entire liberty is accorded to the lunatics resident 
in the town of Gheel and its neighbouring hamlets, to 
the number of 2,000. 

Besides the head physician — Dr. d'Hollander — there 
are six resident medical officers and a number of in- 
spectors. This " colony " system, which is typically 
represented at Gheel, but exists also at Lierneux in 
Belgium and at Dun-sur-Auron in France, may be 
briefly described as the concentration of the insane in 
the private houses of a village, or series of adjoining 
villages, under the supervision of a medical and lay staff. 
A small central hospital serves at once for the purpose of 
a sick-room for patients suffering from physical ailments 
and a retreat for those who are overtaken by recurrent 
temporary attacks of acute insanity. 

Here the patients, when they arrive, are detained a 
short time on trial before they are dispersed among the 
cottages to the care of the caretakers, with whom 
they subsequently remain. The little army of pauper, 
and other patients gathered from the whole of Belgium, 
are distributed over 600 different dwellings, the major 
portion of which are small cottages or small farmhouses, 
in which the more troublesome or poorer patients are 
dispersed, and the remainder are situated in the town 
of Gheel, which is set apart for quieter lunatics and those 
who are able to pay more liberally for their treatment. 
The lunatic shares the usual life of the family, his occupa- 
tion and employments are theirs, and in all cases the 



198 PREVENTION AND TREATMENT 

individual requirements of the patient are carefully con- 
sidered. A strict system of supervision prevails, somewhat 
analogous to that of the Lunacy Commissioners and 
Visiting Justices of England. 

' Family life " is the watchword in Belgium. As the 
family life mainly surrounds the woman, it is the house- 
wife that mainly takes charge of the patient. It is found 
that the influence of children is also incalculable for 
good, and it is positively asserted that never has it been 
known for a child to be injured by a patient. On the 
other hand, no homicidal patients are sent there ; all 
patients are carefully selected. 

Other centres for the family care of insane patients 
have been established, in addition to those in Belgium 
and France, in Germany, Russia, Holland, and Italy. 

The real matter of importance is that family care 
presents a method of dealing with the insane which is 
feasible in a great number of cases, which is curative in 
some, which is improving, tranquillising, and humanising 
in very many, and which in suitable cases, even where 
improvement is not to be expected, is more free, happy, 
and wholesome than existence in an asylum can ever be. 



CHAPTER XV 

THE VALUE OF PROPOSED PREVENTIVE 
MEASURES 

RESTRICTION OF MARRIAGE OF INSANE, 

STERILISATION OF THE DEGENERATE, 

AND THE SEGREGATION OF THE FEEBLE-MINDED 

In the question of marriage, education, and occupation 
the consideration of heredity seems forgotten or wholly 
ignored by the majority of persons. People with neurotic 
heredities marry ; they bring neurotic children into the 
world ; they educate them faultily, and in such a manner 
as to add to their neurotic inheritance ; they allow them 
to choose unsuitable employments ; and finally the 
children develop in their turn nervous and mental de- 
rangements. There is a lack of responsibility, especially 
amongst the poor and ignorant classes, who are careless 
what their progeny may be, what mental or physical 
disabilities their children may inherit, how these shall 
earn their living, who will have to support them, or what 
poverty-stricken, unhealthy, immoral, or secluded lives 
they may have to lead. 

Nowadays, when the maniac, the melancholic, the 
would-be suicide, the imbecile, the epileptic, and the 
habitual drunkard are married and given in marriage, 
the suffering has become so terrible, the contamination 
of the race so great, and the care of the useless offspring 
begotten so heavy a charge upon the community, that 
some effort should be made to stay this curse upon the 
land. At present, with the exception of the idiot and the 
raving maniac, who in the eye of the law are unable to 
make a contract binding on themselves, there is no one 
so diseased, crippled, or deformed that he or she may 

199 



200 PREVENTION AND TREATMENT 

not marry and become the parent of a suffering, helpless 
family, so far as the law is concerned. 

In an ideal community no doubt, the first precaution 
in order to prevent the propagation of insanity would 
be the forbidding of the marriage of unsuitable persons. 

To observe the way marriages are sometimes arranged 
is almost to lose hope for the future of the human race. 
If men and women were racehorses or short -horns, their 
breeding would be studied most elaborately ; all im- 
perfect or faulty stock would be carefully eliminated, and 
everything like inbreeding would, as a matter of course, 
be avoided. 

It would be of immense advantage to the human race 
if we could effect an improvement in the bodily and mental 
capacities of men and women by selective breeding ; if 
the bad stock could be eliminated and the good stock en- 
couraged ; if the State could interfere, with stringent 
regulations of marriage, prohibiting unions of those close 
of kin and the whole class of mental degenerates. It 
is rightly argued that persons tainted with insanity have 
no more right to transmit their disease to a helpless 
progeny than a person suffering with smallpox has the 
right to infect other people by travelling in a public 
conveyance. As with the victim of smallpox, it is 
their misfortune more than their fault ; but society 
is bound to protect itself. The unfortunate few must 
suffer for the benefit of the many. It should be the 
duty of the State to see that such unfortunates are 
protected and cared for, and that their lives are made, 
as far as possible, useful and happy ; but that they should 
be permitted to hand down their disease to innocent 
children, any more than the sick one should be permitted 
to give his smallpox to his neighbour, is unfair to society 
and to the race. 

The greatest danger arises from those who have been 
once insane. Owing to pressure of accommodation in 
the county asylums it is necessary to discharge patients 
as soon as possible, and there is no doubt that in many 
instances the recovery is not firmly established ; fre- 
quently these " recovered " patients reappear at a 
shorter or longer interval on the admission list of the 
same or some other allied institution. Recurrent in- 



PROPOSED PREVENTIVE MEASURES 201 

sanity in this respect is much more dangerous than 
permanent insanity, because the subject suffering from 
recurrent insanity is periodically given his or her liberty, 
and the woman often becomes the mother of children, 
has a relapse, and goes back again. Figures which would 
show the number of children borne by women discharged 
from asylums would be very interesting and instructive 
reading. Unfortunately they do not exist, and even if 
they could be obtained they would probably tell less 
than half the tale. The male lunatic would still have 
his progeny unaccounted for and unrecognised, and he 
is obviously a greater power in the production of offspring, 
good or bad, than the female. 

I can quote however one case of a female patient now 
in Colney Hatch that has been brought to the notice of 
the Asylums Committee of the London County Council 
as recently as October 191 1. The woman's history 
includes the following startling facts : 

15 times admitted to and discharged from the 

institutions controlled by the London County 

authority. 
11 times admitted to and discharged from other 

asylums. 
13 children born to her, of whom five are dead and 

two show signs of insanity. 
2 of her sisters were lunatics ; one committed suicide, 

the other died in an asylum. 
2 of her aunts are now in asylums. 

The latest figures available show that 17,976 patients 
were discharged from London asylums as " recovered " 
in the fifteen years ending December 31, 1909. No fewer 
than 5,107 were readmitted up to March 31, 1910, or 
28*69 per cent. ; and nearly half of these, over 12 per 
cent., were readmitted within a year. An examination 
of the family history of 1,834 patients showed that 
there were : 

2 instances of six insane in a family. 

«J >> )J *"C ,, ,, ,, 

!2 „ „ four „ 

j »> }> ruree ,, ,, ,, 

752 „ „ two 



202 PREVENTION AND TREATMENT 

The medical superintendent at Bexley Asylum has also 
reported that among his patients he had traced blood 
relations who were, or had been, under treatment in a 
London or other asylum as follows : 

47 instances of father and son. 

53 ,, father and daughter. 

32 ,, mother and son. 

74 ,, mother and daughter. 

45 ,, brothers. 

64 ,, brothers and sisters. 

69 ,, sisters. 

1 ,, a father, mother, son, and daughter. 

2 ,, father, son, and daughter. 
1 ,, mother, son, and daughter. 

1 „ three brothers and two sisters. 
4 ,, father and two sons. 

4 ,, mother and two sons. 

2 „ mother and three sons. 

2 „ two brothers and one sister. 

1 „ four brothers. 

6 „ three brothers. 

Before marriages are arranged, inquiry should be made 
as to whether there is any history of insanity in the 
families of the contracting pair. If there is insanity 
in the family, we shall have to consider in how many 
members and how many generations it has shown itself. 
If it has occurred in one of the parents, what was the 
age of the parent at the time of its appearance ? Did 
it appear when the parent was young, at a time when 
obviously it must have been inherited, or did it manifest 
itself later in life with a cause and a history which showed 
it to have been acquired ? What was the age of the 
parent when the child was born, and was it born before 
or after the disorder commenced in its parent ? 

It would be of advantage to the race if no person who 
has had an attack of unsoundness of mind would marry 
during the child-bearing age ; if no epileptic, who has 
become subject to the disease before twenty-one, would 
marry ; and no person who suffers from mental enfeeble- 
ment in any degree would contract marriage. 



PROPOSED PREVENTIVE MEASURES 203 

It is positively criminal to withhold the fact of a girl 
having been insane from a man about to propose marriage. 
But it is done by parents, or else the history of the attack 
is minimised and spoken of as only nervousness or hysteria. 
Some people even think that marriage may effect a cure ; 
as a matter of fact the danger of a relapse is very great, 
for the woman has to face the trying periods of child- 
bearing. No one who has had one attack of insanity 
can be pronounced free from the risk of another, for it 
is a disease which confers no immunity in the future on 
its victims like some others we have to treat. On the 
contrary, each attack, if there be more than one, adds to, 
and does not take away, the liability to others. 

The misfortune is that most people get engaged, and 
ask our advice after, and that is the real reason why 
medical advice is so seldom followed. The misfortune 
is real, for such tainted persons make ill-judged selections. 

Passing to those persons who have not had actual 
attacks of mental unsoundness, but who by family in- 
heritance are deeply tainted with the disease, no definite 
rules as to marriage can, in the present state of knowledge, 
be laid down. The question must be left to experts. 
The maternal heredity is much the most important. If 
the woman is healthy and only the man has a bad family 
history, the chances of the children becoming affected 
are small ; but the man's personal history and physical 
and mental state should be carefully examined, as there 
will always be a risk. Where both parties have a bad 
family history, the chances of tainted offspring are 
enormous, and marriage should be forbidden, and be 
made punishable if they are blood-relations. There 
seems a tendency among these neurotic folk to choose 
for their partners people of a like nervous temperament, 
and, from a shyness which is characteristic and constitu- 
tional, they often choose cousins whom they have long 
known in preference to strangers whom they know not, 
and are too shy to approach. 

The worst is that the partner does not always become 
insane, but remains in that first stage, manifesting 
merely a " lack of self-control/ ' giving vent to his or her 
feelings on very slight, or without any, provocation. 
Such people are terrors to the household, and, curiously, it 



204 PREVENTION AND TREATMENT 

is not they who go mad, but not infrequently the man or 
woman who is tied to them for life. At all events it is 
not by any means rare to be told, " I shall go mad if 
I have to stand her, or him, much longer." Many cruel 
husbands are the cause of the nervous breakdown of the 
woman, and it is not the drink that causes the cruelty, 
as the poor wife supposes, but frequently both drink and 
cruelty are the symptoms of a hereditary taint. On 
the other hand, a woman, herself on the borderland, can 
by her temper and conduct drive a man, who has the 
domestic trouble added to his other cares and worries, 
to insanity. Many a desperate deed, chronicled in the 
newspapers, is the mere outcome of a mind driven tem- 
porarily insane by another tainted one. 

The children of an insane parent are not all insane, 
but it is certain that every child — whether it becomes 
insane or not — carries about with it through life a ten- 
dency to insanity, and there can hardly be a more terrible 
heritage. And it must not be forgotten that insanity 
is not the only result of an inherited predisposition ; 
nervous diseases of all kinds may be developed in the 
children of insane parents, besides epilepsy, dipsomania, 
criminal tendencies, idiocy, and the like. People boast 
that there is no insanity, when nearly all their offsprings 
are the victims of some nervous complaint, some eccen- 
tricity, perversion, obsession, or mere incapacity to earn 
a livelihood for themselves. 

Although not all children of an insane parent are 
insane, yet it is impossible to predict with certainty that 
this one or that one will escape. The most unlikely and 
most steady-going are often those who break down under 
excessive strain, while others who have been obviously 
eccentric remain always eccentric and never go beyond. 
Now, although we cannot forbid all such children to 
marry, it is most important that they marry partners 
who are themselves free from all nervous disorders, and 
whose inheritance is untainted by any such disease. 

The difficulties in the practical application of eugenics 
are numerous. First of all, the people to whom it is 
essential that this gospel of deliverance should be preached 
are precisely the people who pay no heed to it. Then 
it must be remembered that people do not marry merely 



PROPOSED PREVENTIVE MEASURES 205 

for the " procreation of children," but also for ' the 
mutual society, help, and comfort that the one ought 
to have of the other/' Eugenists recognise that it would 
be a mistake to expect that human beings can be mated 
the same as animals for the improvement of the breed. 
They know that marriage is not a question of the head 
only, but also of the heart, and any attempt to control 
it would meet with difficulties. For although physical 
beauty — that is to say, health — determines marriage to 
some extent, men and women marry also for the pleasant 
companionship, help, and comfort which the contracting 
parties hope to gain from one another. Moreover, though 
by selection in marriage the child may be born healthy, 
nothing will be gained if the parents are poor and badly 
educated and cause the child to grow up feebly, because 
of improper or insufficient nourishment, insanitary 
surroundings, and lack of that mental and moral educa- 
tion in early childhood which only the parents can 
supply. We must also remember the influence of ex- 
ternal environment, and not jump to the conclusion that 
every case of apparent slowness and backwardness is 
due to organic defects. A great deal is said about the 
propagation of the criminal classes, and where it depends 
upon true mental defect I believe that criminal tendencies 
can be propagated ; but my experience of the children of 
the depraved and criminal classes has taught me that, 
taken early enough and placed in good environment, a 
large number turn out thoroughly decent, hard-working, 
and law-abiding men and women. 

Finally, if there is to be restriction in marriage in the 
case of persons who are unfit to marry, one has to face 
the alternative, which is so often forgotten, that marriage 
is not an essential preliminary to procreation. It must be 
borne in mind that there is such a thing as bastardy. 
And thus we are confronted with the question as to how 
far the State has a right to employ coercion or restraint. 
In the case of the actually insane, there is, and can be, 
no dispute. But where a married man or woman has 
once been certified as a lunatic, and proves to have been 
only temporarily deranged, it is evidently a matter of 
much difficulty and delicacy to decide whether he or she 
shall under any or what circumstances be allowed to 



206 PREVENTION AND TREATMENT 

resume the family life at the risk of perpetuating so 
terrible a calamity. There are some forms of mental 
alienation which are patently associated with the bodily 
condition of the sufferer, and in which the chances are 
enormously on the side of the transmission of a taint to 
the subject's offspring. In a case of this sort there ought 
absolutely to be no hesitation. But it is very hard to 
see how the victim of a temporary lapse could be 
authoritatively dealt with after an apparently complete 
recovery, and indeed it is not certain that such a lapse 
necessarily indicates the transmissibility of the taint. 

But if legislation is unattainable, to what must we 
look for the regulation of marriage of tainted persons ? 
Clearly we have only public opinion to call to our aid, 
although public opinion requires to be educated for a 
long period before it will be of much service. How many 
a man or woman do we see whose health and mind are 
sacrificed on the altar of marriage, who might have led 
a happy and useful life if compelled by public opinion 
and judicious advisers to remain single. We can only 
trust that by education, by continual ventilation of the 
subject, and exposure of the evils arising from its neglect, 
public opinion may in time be directed towards it, so 
that people will be forced to look upon the act of giving 
birth to an insane child as a cruel sin. 

With birth the evolution of the human being is nine- 
tenths completed, therefore the most vital interests of 
society lie in caring for the unborn, not for the born ; 
and it is insensate folly to leave this to the ignorant and 
thoughtless desire of the individual. Hence it has been 
proposed to deprive the unfit, the incorrigible criminal, 
the imbecile and chronic insane, the inebriates and incur- 
able epileptics, of the possibility of parentage by sterilising 
both men and women. This it is said would involve no 
hardship on the individual, yet it would protect society. 
Obviously our experience is too limited to allow us to 
urge conscientiously such wide-spread sterilisation of all 
mental defectives. There is not yet sufficient knowledge 
available on the various factors to enable medical men 
to render trustworthy advice to the Legislature. Medical 
men do not yet know sufficiently accurately what qualities 
are heritable and what qualities are not. 



PROPOSED PREVENTIVE MEASURES 207 

The surgical operation in itself may be absolutely 
without danger, but experience proves that there is a 
strong repugnance against all coercive or repressive 
legislation affecting the social customs and habits of 
society, which is shown by the constant desire to 
evade it. 

Sterilisation might be necessary as a preventive 
measure if lifelong care were not available, for there is 
undoubted danger to the community from the large 
number of feeble-minded who are not under supervision, 
and who are specially liable to have illegitimate children, 
or to make ill-advised marriages. But the disadvantages 
of such a procedure as sterilisation are great, and lifelong 
supervision, which, though more costly, is so necessary 
for other reasons, should, if efficient, be an equally good 
safeguard against the propagation of the taint to future 
generations. 

Parents of feeble-minded children do not as a rule 
live long enough to be life-long guardians, and they often 
meet with little success in controlling the child, so that 
they are not likely to be able to control the adult. 

The Special Classes of the County Council do not include 
the very deficient and troublesome imbecile who is not 
bad enough for an asylum, and the feeble-minded children 
they do train are let loose upon the community at the age 
of sixteen, at a time which is undoubtedly the most 
critical in their life history, both for themselves and,, 
particularly in the case of the girls, for the next and 
succeeding generations. It is the child who, only slightly 
defective, may acquire, as the result of education, 
a superficial veneer sufficient to allow a return to the com- 
munity, who constitutes thereto a very grave danger. 

We require increased powers of detention of feeble- 
minded persons beyond the age of sixteen, whose conduct 
considered apart from " facts indicating insanity/' such 
as would form the basis of a lunacy certificate, proves 
their incapacity of managing themselves and their affairs 
with ordinary prudence, thus rendering them a danger 
to themselves and the community. 

Special training in special schools, classes, or institu- 
tions may be, and no doubt often is, of great benefit to 
children of this description ; but no training can supply 



208 PREVENTION AND TREATMENT 

mental fibre which is lacking in the natural constitution, 
and whatever improvement may result, the expense and 
the trouble are thrown away if the child, later on, is 
thrown out into the world without being able to protect 
and take care of itself. Protection, shelter, and care must, 
as a rule, be lifelong and permanent. 

In the ruder state of society which has passed away, 
little heed was taken of these unfortunate children, and 
many of them, no doubt, died comparatively early in the 
struggle for existence. But we have learned to think 
more tenderly of the inferior members of our race, and 
we seek to protect them from the calamities and suffer- 
ings to which they are naturally exposed, and to preserve 
their lives to the utmost. But in so doing we incur 
another responsibility — namely, that of preventing, so 
far as we reasonably can, the perpetuation of a low type 
of humanity, for otherwise, the beneficence of one genera- 
tion becomes the burden and the injury of all succeeding 
ones. 

What we want for them is self-paying industrial and 
farm colonies, where they might remain working and 
playing all their lives, children to the end ; but happy, 
harmless children, instead of dangerous and degraded 
ones. The committal of feeble-minded persons to prison 
is indefensible, but it is also at present inevitable. There 
is no place other than the prison for the weak-minded 
law-breaker who cannot be certified as insane. Such 
provision would be only a rational extension of the prin- 
ciple of indeterminate sentence, and, if safe-guarded by 
careful and repeated expert examination and observation, 
could do no injustice and would greatly diminish crime 
in the immediate future. 

The Royal Commissioners on the Care of the Feeble- 
minded have approved of such a plan, although the 
details have been subjected to considerable criticism, 
chiefly because the method suggested by them seems to 
be an expensive one. But it can be made economical 
and even self -paying. 

We want more training institutions for the weak- 
minded children of the poor, the older institutions not 
being primarily intended for the pauper class and the 
whole Poor Law accommodation being shockingly inade- 



PROPOSED PREVENTIVE MEASURES aog 

quate. From the training institutions the children should 
be sent to farm and industrial colonies. 

A practical attempt has been made in the new farm 
colony for the feeble-minded at Hildenborough, near Ton- 
bridge, and is an example of the methods by which we 
endeavour to combat what threatens to be one of the 
most crying evils of the age. Here defective children 
of either sex (in most cases the offspring of defective 
parents) are rescued from the dangers of the street, 
the prison, or the workhouse, brought up in clean and 
healthy surroundings, and taught to labour with their 
hands. It has been found that though many of these 
children can neither read nor write, and indeed are 
totally incapable of acquiring the ordinary rudiments 
of education, they show a certain amount of aptitude 
for manual labour. At Hildenborough, therefore, they 
are given every chance of learning something which 
will enable them, if not to support themselves, at least 
to keep them from swelling the already over-crowded 
ranks of the unemployable. 

Another successful colony is that at Sandlebridge, 
near Manchester, founded by the Lancashire and Cheshire 
Society for the Permanent Care of the Feeble-minded. 

The industrial colony might, in course of time, become 
to a large extent self-supporting, for the work that could 
be done there— upholstery, tailoring, shoemaking, basket 
and brush-making, rug-making, joinery, etc. — might 
become paying industries. 

National progress can take place only when means 
are taken to increase the fit and decrease the unfit. 
The establishment of suitable farms and industrial 
colonies is the only method whereby society can be pro- 
tected from the feeble-minded. There they would be 
far happier than in the outside world, and would con- 
tribute to their own support, but would be denied the 
opportunity of procreation. 

Nothing is more wasteful than the army of degene- 
rates who, when they are not living at the cost of the 
tax-payer in workhouses or prisons, are wandering at 
large, idling, pilfering, injuring property, and polluting 
the stream of national health by throwing into it human 
rubbish in the shape of lunatics, idiots, and criminals. 

14 



210 PREVENTION AND TREATMENT 

Farm and industrial colonies should be organised to 
accommodate the whole of the defective classes, and their 
admission made compulsory and detention last during the 
term of their natural lives. This plan is advocated not 
only on humane and social grounds, but for economic 
reasons as well, for it will not only elevate the race 
mentally and physically, but it will be ultimately a paying 
investment for the State by drying up the perennial 
stream of the fountain, and in time lessen the burden of 
taxation on the people. It must be remembered that 
the neglected feeble-minded in our midst are already 
costing the country a large sum for maintenance in 
workhouses, prisons, reformatories, and inebriate and 
other similar institutions, whereas, if " detected early 
and protected always," they could be trained to honest 
labour, which would at any rate help towards their 
maintenance, and by segregation the great and costly 
peril of transmitting to succeeding generations the 
hereditary tendency of mental defect would be dimin- 
ished or avoided. 

The obstacles encountered on the practical side of 
this plan are, of course, very great. One of the chief 
hindrances lies in the difficulty in estimating the degree 
of degeneracy. Another is that constitutional immorality 
is not yet entered on the list of crimes. Assuming that 
we can discover at an early stage premonitory signs of 
moral obtuseness, which promise little that is good in 
the future conduct of the individual, there is no civil 
legislation which will allow the enforced separation from 
society of an element which, although it is shown to be 
predisposed to crime, has as yet in no way offended. 
The only standard recognised by law is the obstinate 
repetition of crime. But even this is not altogether 
reliable, because the repetition is often the outcome of 
the conditions of imprisonment, at least in the case of 
some of the lesser crimes.* (See also Chapter XXVII.) 



* Since writing the above, the Government has introduced a Bill 
for the restraint and care of those mentally defective, who at present 
are not certifiable, proposing to place them under guardianship or 
to send them to institutions, and imposing penalties on any one 
marrying or attempting to marry a person alleged "defective " under 
the Act. 



PART IV 

THE VARIETIES OF INSANITY AND 
FEEBLE-MINDEDNESS 



211 



In this part of the book we shall attempt to describe 
the various types of mental disease. These types are 
merely convenient labels for grouping together more or 
less similar sequences of phenomena, whose borders are 
indefinite and to a certain extent arbitrary, and which 
frequently overlap. To classify the types of insanity 
on an anatomical or pathological basis would certainly 
be more scientific, but the day has not yet come for it. 
At present too little is known of the mental functions 
of the brain, and of the pathological changes in its struc- 
ture when the mind is disordered, to admit of such a 
classification. Therefore, we must be content with a 
classification by symptoms, which, if less scientific, has 
its practical utility, especially for a book which appeals 
to a wide circle of readers. 



212 



CHAPTER XVI 

MENTAL SYMPTOMS ACCOMPANYING BRAIN 
FATIGUE (NEURASTHENIA) 

INDECISION, OBSESSIONS, AND MORBID FEARS 

Before describing the initial signs of the various forms 
of insanity, it will be advisable to consider some of the 
mental symptoms of fatigue and exhaustion of the 
nervous system, from which, more or less, every man 
surfers nowadays, at one time or another, although 
only temporarily. 

Fatigue of the brain and nervous system is a complaint 
which attacks chiefly persons who are subjected to pro- 
longed mental application combined with worry and 
responsibility, and shows itself in irritable weakness, 
exaggerated sensibility, loss of will-power, and lack of 
inhibition and control. There is a more or less pro- 
nounced loss of power in all the faculties, to which are 
incidentally added fixed ideas and obsessions, and some- 
times exaggerated emotionalism. 

In this state the patient is conscious of a want of brain 
tone, a sluggish action of the mind, and of a deviation 
from his normal condition of intellectual acuteness, 
activity, and vigour. He is painfully sensible of feeling 
mentally below par, and recognises his inability to use 
efficiently his mental powers. The power of attention 
is weakened, and the memory either wanders or is inco- 
herent in its associations. The person is inattentive 
from sheer lack of power of application and mental en- 
durance. The effort to think is irksome and painful, 
causing, if persevered in, painful confusion of thought 
and mental depression. His thoughts attach themselves 
to secondary points, to futile details ; he sometimes reads 
whole pages without having understood what he has 

213 



214 THE VARIETIES OF INSANITY 

read. There is an inability to " make up the mind," 
to come to a decision, to exercise a choice. The patient 
will hesitate a long time before he is able to decide 
whether to put on the right or the left boot first, which foot 
to begin with in going upstairs, which pen to select out 
of a tray, what word to use to express his meaning, 
whether to walk this way or that, whether to take a 
stick or an umbrella, and so on with all the decisions of 
life. He worries usually over such trifles as whether he 
stamped a letter before posting it, whether it was properly 
addressed, whether he left a certain door open, or closed 
another door, and so on. 

Irresolution, hesitation, and the general enfeeblement 
of the will-power react upon the character. The formerly 
cheerful man or woman, accustomed to bear equably the 
untold petty annoyances and cares of the present age, 
now becomes reactive and irritable to all noises ; the 
sounds of the street, the cries of children, the presence 
of members of the family, all cause intense annoyance. 
Such persons cannot meet the ordinary ills of life with 
a normal degree of fortitude ; they grow discouraged 
with the smallest failures, magnify every obstacle, and 
profess inability to surmount it ; they create painful 
emotions by representing to their minds ideas of danger 
or of evil or fear. They seem incapable of looking at 
a question calmly. Slight troubles and indispositions 
affect them seriously, and grave ones often cause profound 
depression. They make mountains out of molehills, then 
toilfully climb these self-created mountains, when a clear- 
eyed reason would discover that the mountain needs no 
removal, being only a molehill. 

There are always physical signs of exhaustion as well, 
insomnia being the most frequent symptom. Others 
sleep in a heavy, unrefreshing way, and the want of 
restful sleep aggravates the condition of course. 

Sometimes the nervous prostration seems ingrained in 
the person. Such are literally " born tired." Continued 
application, in these persons, causes an undue sense of 
fatigue, headache, and sleepiness. They become hypo- 
chondriacal and self-centred. They are easily turned 
aside from their work. Their power of attention is very 
poor. They are easily baulked in any undertaking. 



MENTAL SYMPTOMS OF BRAIN FATIGUE 215 

Others are born "highly strung" and unusually sen- 
sitive, and to them the teaching of mental control in 
childhood and youth should have been compulsory. But 
this in many cases has been neglected. 

The varieties of mental aberration due to nervous 
exhaustion comprise quite a wide range of symptoms 
of varying gravity, some of them comparatively 
trivial and others of serious import. In all there is a 
decided nervous weakness involving, more or less, that 
mental function which we call the will. Except in their 
most pronounced development, or when associated with 
clearly insane manifestations, they seldom are met with 
in the asylums ; but they are common in the experience 
of private specialists, and in some of their mildest forms 
can almost be said to be matters of every day experience. 

It results from the weakening of mental control that 
the patients suffering from nervous exhaustion are 
powerless to resist the invasion of certain ideas that 
obtrude themselves upon their minds and hold for the 
moment an undivided empire over them. Some of these 
obsessions are harmless and meaningless, as for instance 
the desire to repeat certain words or phrases, such as a 
slang expression or a popular air, to count objects of no 
interest, or to touch some article of furniture. Others 
are fretful to the individual and dangerous to other 
people, as the desire to kill, to commit suicide, or to 
steal. They are recognised by the subject as being 
foreign to his personality and his modes of thought, as 
unreasonable and morbid, and are not, at any rate in 
most cases, blended with his individuality. They are 
simply ideas or feelings that he cannot get rid of at the 
time. Practically they are only exaggerations of the ex- 
periences of most, if not all, normal individuals, and it is 
only through the degree of this exaggeration that they carry 
their victims over the borderland of mental health. We 
are all of us subject to morbid mental conceptions, but 
with most of us these are only transient, and are fully 
controlled by the intelligent will. It is only in certain 
conditions of nervous exhaustion or in persons who are 
naturally defective that these conceptions become actual 
obsessions. 

Particularly painful are the obsessions of fear. They 



216 THE VARIETIES OF INSANITY 

are less common than the obsessions of doubt, and usually 
follow them. In these the patient surfers from an 
uncontrollable dread, usually confined to a single object 
or class of objects. We have the fear of open places, 
in which the patient cannot cross a square or even the 
street — agoraphobia ; and its opposite, where the same 
sort of dread is excited by being in an enclosed space — 
claustrophobia. 

When persons afflicted with agoraphobia enter an 
open space or pass through a street that is devoid of 
people, they are immediately overcome by the imperative 
idea of the impossibility of going on, and thus they be- 
come so anxious and nervous that they are actually 
paralysed ; while if they keep close to the houses or are 
accompanied by some one, they have no difficulty what- 
ever. The painful situation in which the patient finds 
himself leads to anxiety, as a result of which the painful 
feeling becomes still more intense. 

There are a large number of other forms, such as fear 
of lightning, fear of precipices, fear of blood, etc. Others 
manifest a dread of cancer, or other special disease, to 
such an extent as to cause them to live in a state of 
mental torture, and to render themselves obnoxious to 
other people. Some have an aversion to the contact of 
certain animals — cats, mice, toads, etc. The patient 
recognises the absurdity of his dreads, and in a feeble 
way strives against them ; but the lassitude of will is 
too great to be overcome, and he returns to his fears and 
anxieties. The claustrophobe who is shut up in a rail- 
way carriage or the agoraphobe who is in an open space 
is as thoroughly and completely aware of his safety, and 
of the irrationality of his terror, as the person on the 
edge of the cliff who is safeguarded by a stout railing 
from falling over, but none the less is he incapable of 
utilising his knowledge to suppress his panic. 

In some persons there is a morbid anxiety as to health, 
and extremely exaggerated, if not illusory, ideas as to 
the existence of certain bodily disease, leading to the 
concentration of the attention upon, and consequent 
exaltation of physical sensibility, resulting often from 
passing physical sensations or slight ailments, which 
eventually assume to the deluded imagination a grave 



MENTAL SYMPTOMS OF BRAIN FATIGUE 217 

and significant character. There is an apprehension of 
fear of disease, not a genuine conviction, hence the patient 
talks to every one he meets about his ailments to get 
some further clues about their realities. At first he will 
be amenable to reason, but if not dealt with firmly 
while the nervous exhaustion is treated, which lies at 
the root of his trouble, his fear may give way to a de- 
cided belief, a fixed idea. The only difference from actual 
insanity is then that the hypochondriac, as we will call 
such a patient, is, however convinced of his trouble, 
still looking for sympathy and possible help, whereas the 
insane person is as a rule too downcast to care whether 
sympathy is offered or not, and would prefer death to 
cure. 

The origin of the fear of such neurasthenic patients is 
simply explained : they are results of ideas that would 
leave only fleeting impressions on a healthy brain, but 
which leave an exaggerated and lasting trace on the 
exhausted organ. They may originate with some special 
experience : an apparently narrow escape from being 
run over may be the inciting cause of a dread of crossing 
streets ; a sudden morbid impulse or suggestion to throw 
one's self down may be the cause of a phobia as regards 
all high places. In all cases it is the weakened inhibition 
that is at fault. It is easy to see how almost any variety 
of obsessions of dread may thus arise, and most of us can, 
from our own experience, appreciate their possibility. 

A person may have a fear of railway trains, of theatres, 
of church, of crowded and solitary places, of social en- 
tertainments ; but in each of these it may be the same and 
only fear — that of fainting. Another person fears water, 
knives, firearms, high places, and gas ; but the real fear 
is of suicide, and the objects are conceivable methods 
by which suicide can be effected. 

These peculiar dreads and oppressions do not tincture 
the whole being, as the fixed ideas of the insane do. 
They occupy but a part of the mental life of the sufferer, 
and, unlike insanity, do not colour or pervert the ordinary 
avocations. They are more or less arguable, more or 
less kept in their place by the judgment of the sufferer, 
who does not lose all sense of relative values. 

If these vague and illusory fears should stiffen into 



218 THE VARIETIES OF INSANITY 

delusion, then the case would pass into insanity. Some 
of these apprehensions do come perilously near it. A 
fear of doing some wrong recurs until it possesses the 
mind ; the besetting thought looms larger and larger until 
it assumes the garb of a temptation. Fortunately, the 
large majority keep on the hitherside of the line of 
insanity, and are thus preserved. 

Obsessions often lead up to impulsive actions. The 
morbid impulse is another defect of mental and emotional 
control, the existence and modus operandi of which can 
be readily appreciated from one's own experience. Most 
of us have experienced at times a morbid impulse to do 
something of which our better judgment disapproved. 

Such impulsive actions are performed consciously by 
an individual, apart from and in spite of the intervention 
of the will-power. The will, we must remember, is the 
power not only to do something, but also to leave some- 
thing undone ; it not only produces impulse, but also 
inhibition, and, like all the higher forms of mental activity, 
the inhibitory will-power has but an unstable and 
precarious existence, simple fatigue being sufficient to 
render us unable to control our reflexes. Even people 
who are completely sane have their brains traversed by 
foolish abnormal impulses, but these sudden and unusual 
conditions do not pass into action, because they are 
controlled by a contrary force. 

The more detrimental the impulsive action is to the 
patient or to others, the greater the struggle and the 
mental distress. When the act is committed, there is 
usually a feeling of relief. But if the action is immoral 
or harmful, this feeling of relief is sooner or later followed 
by one of remorse and self-reproach, with often a great 
anxiety, lest the obsession should recur. 

These impulses are as manifold in their forms as are 
the obsessions of doubt or fear, and vary in their im- 
portance and severity from the simple easily rejected 
suggestion, as to say or do something wrong, to the most 
inconvenient or dangerous impulses to serious crimes, 
such as assaults, arson, suicide, or homicide. 

The sight of a particular person or a weapon arouses 
within them the unnatural desire with all its accompany- 
ing mental torment. Some of them place themselves 



MENTAL SYMPTOMS OF BRAIN FATIGUE 219 

voluntarily under restraint to avoid the temptation, or 
take practical means to place themselves outside the 
reach of their abnormal passion. They feel that their 
wills are yielding to the power of the besetment, and 
when once they yield the crime must follow. Many of 
them seek medical advice to counteract the obsession, 
for fear their dangerous impulses might be put into 
action. Theft is very common. The article stolen is 
usually not made use of, or is replaced unawares. It is 
the shame of being regarded as a genuine thief that pre- 
vents a frank confession. The majority of patients, 
however, have only a " fear " of stealing when seeing 
valuables exposed ; they surfer agonies in consequence, 
but their impulse is not carried into action. (See 
Chapter XXVII on " Insanity and the Law.") 



CHAPTER XVII 
THE MENTAL SYMPTOMS OF HYSTERIA 

Hysteria is essentially a disorder of that part of the 
nervous system which subserves the emotional nature. 
The greater number affected are women ; it is only 
occasionally to be met with in men. The mental 
symptoms of hysteria resemble in great measure those 
of nervous exhaustion, though the causes are not the 
same. We see defective will-power, want of self-control, 
instability of the emotions, a tendency to impulsive 
actions, self-consciousness, and an irritability of temper. 
Such patients crave for excitement, novelty, and the 
sensational, and their desire to attract attention and 
sympathy is so great that they will, perhaps half 
unconsciously, exaggerate and even invent symptoms. 
Persons afflicted with this disease have been known 
to starve themselves, to refuse to walk or to speak 
for years, to mutilate themselves, even torture them- 
selves, in order to produce strange and puzzling symp- 
toms. They not only imagine themselves the victims 
of the most diverse and serious diseases, but by some 
obscure power they unconsciously simulate diseases, of 
the symptoms of which they themselves cannot possibly 
have any knowledge. 

In conversation everything is exaggerated with tire- 
some repetition. The superlative degree is called into 
use at every turn. These patients have little power of 
application as a rule, and are always talking of how tired 
and weak they are ; yet they will spend hours in pottering 
about, and give infinite thought and time to trifles that 
ought to be disposed of summarily. 

The most profound disturbances with these cases are in 
the emotional field. All is caprice with them. They 

220 



MENTAL SYMPTOMS OF HYSTERIA 221 

love without measure those whom they will soon hate 
without reason. Instability is the fundamental feature 
of the hysterical character. Inclinations, temper, and 
general feelings all change with incredible rapidity. 
Fickleness and contradictory tendencies are special 
characteristics, and gratuitous insults, meaningless slan- 
ders, and theatrical attempts at suicide are by no means 
uncommon. In their love affairs they must have ro- 
mance, and if they are not sought after, they seek to 
interfere with the love affairs of others. When married 
they are the terror of husbands, who find all plans of 
conduct towards their wives a failure, for hardly has the 
husband determined on one line of conduct, than he finds 
his wife changed again. 

Hysterical patients are very uncertain elements in the 
family life ; self-absorbed and selfish, everything must 
bend to their feelings and their views. If the self-feeling 
takes a hypochondriacal turn, as it often does, the whole 
household is kept busy ministering to their slightest feeling 
of discomfort, which is dwelt upon and exaggerated till 
the patient grows to believe himself to be suffering cruelly. 
The patients are untruthful and unreliable, preferring 
deception of all kinds, without any apparent reasonable 
object, to open, straightforward conduct. They are 
unduly excitable, their responses to everything are too 
keen, their sensations too easily aroused, and they give 
way to emotional outbreaks often on the slightest provo- 
cation. They are far too easily influenced by environ- 
ment, and become unduly enthusiastic over any cause they 
espouse. Their enthusiasm leads them into all sorts of 
headlong acts ; their obstinacy is extreme, and their 
regard for the point of view of others is entirely swallowed 
up in their own way of looking at a given thing and 
dealing with it. 

Another mental characteristic of hysterical persons is 
their constant tendency to mental abstraction, to a kind 
of self -hypnotism in a waking state. Their attention soon 
wearies, and they become absent-minded, they dream, 
they abstract themselves, so to speak, from their sur- 
roundings. Occasional absent-mindedness is met with 
in many mental states, normal and abnormal, but those 
who are brought into close daily contact with hysterical 



222 THE VARIETIES OF INSANITY 

persons will notice that they have a constant tendency 
to become dreamy. They are very susceptible to sug- 
gestion and auto-suggestion. 

The dreamy states that are experienced in some of 
these hysterical cases may be of short or long duration, 
and may or may not be accompanied by convulsions. 
Sometimes the patients go about in these dream-states, 
performing various acts with little or no recollection of 
them on returning to consciousness. In other cases 
they appear to see visions, to hear beatific music, or 
to undergo frightful experiences, or pleasurable ones, 
acting the while in the character of imagined experiences, 
regardless of all efforts of the bystanders to " bring them 
to their senses/' Some grow extremely fantastic or 
silly or sentimental in behaviour, laugh and cry up- 
roariously, scream, sing, or shout. 

There are cases where the patient seems possessed of 
two or more personalities, so that in one state she seems 
conscious of certain experiences, and lives up to a certain 
character, while in another state she seems an entirely 
different being. In each state she remembers only the 
events of the life which corresponds to her present state, 
and forgets those of the other. 

We may dismiss the supposition that hysteria is 
" humbug/ 1 There may be malingering as among 
any other class of patients ; sometimes perhaps the 
shamming and hysteria have developed side by side. A 
patient cannot sham symptoms of which she has never 
heard. 

In true hysteria the anomalies of character are accom- 
panied by definite physical signs. Almost any nervous 
disease may be imitated by hysteria. There is often 
sensory disturbance, shown by increased sensibility or 
painful sensibility in various parts of the body. There 
is often motor disturbance, such as spasms, the lump in 
the throat or " globus " being very common, vomiting 
through spasm of the stomach, difficulty in swallowing 
through spasm of the oesophagus leading to great wasting 
from want of solid food, bronchial spasms leading to 
attacks of asthma, and lastly spasms of limbs and groups 
of muscles, imitating in its worst form, when accom- 
panied by convulsions, an epileptic attack. Besides 



MENTAL SYMPTOMS OF HYSTERIA 223 

rigidity and tremors, paralysis is very common, and is 
distinguished from genuine lameness by the fact that the 
hysterical woman makes no attempt to move the limb, 
and by the presence of muscular tone and the electrical 
reaction. 

The latest hypothesis of hysteria is that the disease 
is a mental disorder, the symptoms of which indicate 
what is going on in the subconscious mental life of the 
individual. From birth onwards our lives are built on a 
double principle. We have ostensible personalities and 
concealed personalities, and though the two may har- 
monise fairly well, they are never fully in accord. At 
every moment we have to discard temptations and 
repress emotions out of harmony with this or that set 
purpose. These emotions and temptations, in spite of 
being discarded and repressed, nevertheless continue to 
be important portions of ourselves, and contribute with- 
out our conscious knowledge to our perceptions and 
our thoughts. 

According to this hypothesis, hysteria originates in 
some shock or disagreeable feeling experienced in child- 
hood or youth. The patient suppresses this occurrence, 
not merely keeping silent about it, but also banishing it 
from conscious remembrance, either by a strenuous effort 
of will or by substituting for it some less disagreeable 
idea. Still the original memory remains in the lower 
consciousness as a permanent source of disturbance, and 
reigning there, unmitigated by the wear and tear of 
the daily conscious life, asserts itself from time to 
time by the production of fits and other hysterical pheno- 
mena. 

Hysterical disorders occur sometimes in children, 
especially the cataleptic condition, in which the limbs may 
remain in an awkward wax-figure-like state. Attacks 
of screaming occur, as well as hysterical epilepsy, which 
can be distinguished from genuine epilepsy by the fact 
that hysterical patients do not hurt themselves when 
throwing themselves about, taking care where they 
propose to fall, whereas the epileptic is so completely 
unconscious that she has no choice. 

The hereditary neuropathic disposition is the principal 
factor in hysteria, and is shown already in childhood by 



224 THE VARIETIES OF INSANITY 

an exaggerated manifestation of the emotions, ready 
tears, excessive temper, anticipation of fear, obstinacy, 
discontentedness, defective ethical and asthetical de- 
velopment and fantastic imagination. Such children are 
given to day-dreaming; they stand like a statue, ap- 
parently lost in thought until spoken to, when they start 
up terrified, and it takes some time before they quite 
know where they are. These dispositions must be com- 
bated in early youth. 

Although it is probably true that hysteria has a sexual 
basis, I am much more inclined to attribute it to sup- 
pression of the instinct in girls of a dreamy nature than 
to an actual shock. In former generations, when girls 
were brought up with the sole idea of marriage and had 
less freedom than in our day, hysteria was a common 
complaint. Sports and exercise, regular work and definite 
pursuits, at all events amongst English girls, have made 
hysteria much rarer. We also know that the menstrual 
disturbances in women are liable to set up these 
symptoms. 

The exciting causes of hysteria are great and sudden 
emotions, such as fear in all its forms. It is of forensic 
importance to mention here the frequency of false 
accusations made by hysterical girls against men, to 
whom they are entirely indifferent, arising from impure 
thought and fear, and a misinterpretation of words or 
conduct, which may have been quite innocent and 
harmless. 

That hysterical patients should sometimes become 
insane is no more than we might expect, considering the 
frequency both of hysteria and insanity, and the fact 
that both diseases own a common origin — namely, 
hereditary nervous taint. 

Patients with hysteria may be afflicted for years. 
Remarkable cures have been effected through hypnotic 
suggestion acting on the subconscious undercurrents that 
have been at work, and attending at the same time to 
the physical health and mental hygiene. 



CHAPTER XVIII 

STATES OF MENTAL EXALTATION AND 
EXCITEMENT 

MANIA 

We have now to deal with the first signs of the different 
varieties of recognised insanity. One of the commonest 
forms is an excitement of the psychical functions, which 
is generally little more than an exaggeration of the normal 
activity with a more or less profound alteration of the 
ordinary mental disposition, an elevated emotion, a 
morbid happiness, with little or no confusion. The 
chief mental characteristic of this disease, known as 
hypomania, is a loss of mental inhibition and consequently 
a rapid, ill-regulated, and easily disconnected train of 
thought. Some accidental attraction arrests the atten- 
tion, but only for the moment ; every arising idea or 
mood, every impulse of the will, is already replaced by 
another before it is properly carried out. Thus, in the 
province of ideas, there arises that phenomenon which 
we are accustomed to call the "flight of ideas," which 
is a term quite appropriate, as, in point of fact, the 
duration of the individual idea appears to be very much 
shortened ; the ideas are " fleeting/' and fade again 
before they have actually attained clearness. 

Such patients attract attention in their families by 
their almost ceaseless activity ; they are extremely ver- 
bose, and unburden their minds even to chance acquain- 
tances. They contrive to be very busy over the least 
little thing, and delight to dabble in first one thing, 
then another, abandoning each as soon as they tire of it, 
whether it is completed or not. Some develop great 
activity in letter-writing, and both in their speech and 
15 22 5 



226 THE VARIETIES OF INSANITY 

in their letters these patients change the subject fre- 
quently and abruptly, failing to finish the various subjects 
that they start. Self-esteem is prominent in these 
patients, and their own point of view, their own desires 
and projects, are the only ones they tolerate. They are 
the prey to their impulses, and, while the mood is commonly 
cheerful, and even exuberant, they become irritated on 
the slightest provocation, but their irascibility does not 
last. 

The main point in this disorder is the pleasurable 
emotional feeling. All their bodily functions are well 
performed, and indeed the patients pride themselves that 
they never felt so well in their lives. Their friends 
comment on how well they are looking and what good 
company they are, often without a suspicion that this 
increased activity and vivacity are the result of a mor- 
bidly excited nervous system. They are active and 
restless. They sleep little, rise early, and are constantly 
eager to do something. Generally the memory is extra- 
ordinarily stimulated. They are often able to recall at 
will whole pages of poetry, to quote extensively from 
standard prose works, and to give dates and details of 
events, all of which would be impossible in the sane 
state. Many of them show a particular talent for the 
resuscitation and embellishment of personal and family 
histories of a scandalous character. 

Such persons are scathing and witty in their criticisms, 
they are fond of " puns " and " gag," and as all their 
personal injuries and affronts from early infancy are fresh 
in their minds, the scope of their animosity is generally 
a wide and varied one. In their power of expressing 
ideas they manifest a wonderful facility, and their com- 
mand of language appears inexhaustible. Not only so, 
but the choice of phrases and words, the flow of conver- 
sation adorned by jests, anecdotes, and pleasantries, 
varied according to their audience, shows a mental bril- 
liancy which is more often than not quite unexpected 
and unlooked for in the individual. 

The good spirits of the hypomaniac seem, excepting 
for occasional slight abatement, to be inexhaustible ; 
they rarely leave him ; they make dangers in- 
visible, misfortunes light, life easy, and its struggle 



MENTAL EXALTATION AND EXCITEMENT 227 

pleasant, with nothing but certain triumph at its end. 
A sudden obstacle sometimes inflames his anger, but his 
capacity for rapid adaptation to new objectives and 
his sense of his own superiority inspire him with a 
tolerance, goodwill, and readiness to forget that render 
the hypomaniac one of the most harmless of lunatics. 
It was to such individuals perhaps that Dryden re- 
ferred when he wrote : 

"There is a pleasure in being mad, 
Which none but madmen know." 

In a little more advanced stage the patient manifests 
marked mental exaltation, which reveals itself in an 
increased tone of self-satisfaction and an exaggerated 
idea of self-importance. Consequently, an over-stimu- 
lated imagination, unguided by a just appreciation 
of its surroundings, leads the subject of this mental 
affection to propound schemes and projects of an im- 
practicable kind, and to express himself in injudicious 
and unwise language. His projects are usually as 
quickly abandoned as they are formed, and embrace 
spheres of labour and enterprise that are unknown and 
foreign to his experience. Such patients will criticise 
and advise upon political, social, scientific, or literary 
subjects, of which they are usually utterly ignorant, 
and often discuss such matters with wonderful acumen 
and cleverness. Although their plans and suggestions 
are usually unrealisable, they are by no means always 
absurd or impossible. Indeed patients in this condition 
have been usefully productive, have solved problems, 
and written even brilliant works. Usually, however, 
their projects are not realisable, they are inclined to 
speculations and to buy things they do not want, and 
therefore, if they have the control over business affairs, 
financial losses or other catastrophes are brought about 
before insanity is recognised by their friends. 

The moral nature of this class of patients usually 
becomes perverted on account of loss of control over 
their baser instincts. They plunge into excesses, and 
squander money over drink and vice to the great distress 
of their families. Their natural affection for relatives 
is, except for selfish reasons, usually in abeyance ; they 



228 THE VARIETIES OF INSANITY 

also manifest an extraordinary animosity towards others, 
even to persons scarcely known to them, which may 
end in foolish controversies, litigations, or criminal 
proceedings. They give pseudo-reasonable and ingenious 
explanations for all sorts of unreasonable things which 
they have done. 

The beginning of a case of hypomania is never 
sudden. One will always find a previous history of 
inaptitude, a gradual increasing incapability for active 
work, melancholic brooding, or hypochondriasis. At the 
conclusion of the maniacal excitement there are also 
often attacks of depression, not to be confounded with 
melancholia, for it is sometimes the natural depression 
which follows the recognition by the patient that he has 
made a fool of himself. This alternating condition of 
exaltation and depression will be described in a succeeding 
chapter. 

In the more advanced states of mental excitement, 
mania proper, the patient becomes more difficult to control. 
His conduct becomes boisterous: he sings, dances, shouts, 
and makes grimaces. There is a greater degree of mental 
obscuration . The flow of words, while facile, often amounts 
to mere repetition of one idea, or of a single train of 
thought repeated over and over again. As the patient 
experiences a greater difficulty in fixing his attention 
upon any one subject, so his ideas become more numerous 
and apparently more incoherent, until in many cases the 
symptom of incoherent speech presents itself. This 
incoherence of speech reveals the extraordinary confusion 
of ideas with which the patient's mind is cumbered. He 
is full of mischief, delights in playing pranks and in 
destroying things just for the sake of seeing the havoc 
he can make ; he keeps his dress and hair in disorder, 
often decorates his person fantastically, and is likely to 
be indecent in talk and behaviour. At first, though 
talking excitedly, he may be able to keep to the point ; 
but as the disease progresses, he is unable to hold to the 
topic of conversation — his mind wanders in the track 
of least resistance. 

The faculty for writing, being of a later development 
than that of speech, shows more clearly this confusion of 
ideas. His handwriting becomes more or less illegible, 



MENTAL EXALTATION AND EXCITEMENT 229 

words are omitted, letters are dropped, he misplaces the 
date and signature, and introduces phrases which have 
no relation to the subject of which he is writing. 

His dislike of friends and relations becomes pronounced, 
and he either treats them with unnatural indifference 
or exhibits a degree of active hostility productive of ill- 
feeling and quarrels. 

All maniacs, especially during the acute stages of the 
disease, suffer from insomnia. Their sleeplessness often 
resists the most energetic treatment. 

As the mental confusion increases, illusions become 
frequent ; occasionally there are hallucinations of a 
visual nature, and delusions are now intermingled with 
the constant flow of words. The individual imagines 
that he has become possessed of great mental ability or 
of extraordinary physical power. Projects that exist 
only in his imagination appear to him as already ful- 
filled : he has become a rich man ; has attained posts of 
high honour ; has succeeded in achieving some wonderful 
mechanical invention, and so on. The entire character 
of the delusion of the maniac is of a fleeting nature, 
changing from day to day. 

A delusion having the same power with a maniac as a 
rational belief with a sane person, it is not surprising 
that acts of violence, extending even to murder and 
suicide, are committed. The patient has lost his power 
of inhibition, and shows a tendency to act upon every 
impulse and idea that comes to him. 

The patient is now in the stage of active maniacal 
excitement ; he is incoherent, and has to be restrained 
to prevent him from hurting himself and others. 

The excitement may be moderate, but there is excessive 
irritability of temper from the slightest causes, so that 
the patient can never be trusted. As soon as an attempt 
is made to restrain the patient or to oppose his plans 
and projects, violent conduct and language manifest 
themselves. He may be witty, playful, jolly, and 
hilarious ; but he is as likely to be irritable, domineering, 
and violent. 

The muscular activity of the patient never seems to 
be exhausted. Often, for day after day and night after 
night, he is in a continual state of excitement, movement, 



230 THE VARIETIES OF INSANITY 

and loquacity. The patient is never at rest. His arms 
are gesticulating violently ; he walks, runs, jumps, rolls 
over the floor, dances, and twists and turns his body 
into every possible shape. At the same time he is rarely 
silent ; he talks at the top of his voice one moment, 
whispers in a low tone the next, and then shouts, yells, 
laughs, sings, prays, curses, and howls, till the room in 
which he is seems like a pandemonium. These are the 
cases that people in general are ready to admit are 
insane ; this seems to be the condition that stands for 
insanity in the popular mind. 

It is well known that such cases can continue their 
movements for many days without sleep or rest and yet 
experience no feeling of fatigue. The reason for this 
extraordinary power of endurance can only be explained 
by the absence of conscious attention and the predomi- 
nance of the unconscious mind, which renders the 
actions of the patient more or less automatic ; there is 
also diminished sensitiveness to pain, to heat, and to 
cold, although there is abnormal quickness of vision 
and hearing. 

The frenzied state may last for days, weeks, or months, 
with alternations of quieter intervals, but without com- 
plete return to a normal condition. During all this time 
the patient has been losing weight, despite perhaps an 
enormous appetite. 

After a variable length of time the violent excitement 
perceptibly decreases, the intervals of quietude become 
longer and longer, and the case enters the period of decline 
of the maniacal symptoms. The individual becomes 
mildly melancholic, and gradually passes on to a more or 
less complete recovery. 

In those cases that become chronic the patient, after 
long-continued periods of excitement and repeated 
spells of frenzy, shows a progressive exhaustion of the 
brain powers and becomes apathetic ; his mental vitality 
departs, and he is left in a condition known as secondary 
dementia — reduced to a level beneath that of the beasts 
of the field. 



CHAPTER XIX 

STATES OF MENTAL DEPRESSION 

MELANCHOLIA 

Excessive and unreasonable apprehensive depression is 
one of the commonest symptoms of insanity, and forms 
the prelude to many mental diseases. It may be simple 
mild depression ; the patient feels bad, out of spirits, 
and cannot explain the reason or divest himself of the 
feeling. It is such depression as, in a lesser degree, 
every man or woman may become subject to. 

All persons of a nervous temperament are very sensi- 
tive and therefore more liable to melancholy. They 
feel pleasure keenly, but they also tend to feel 
pain intensely, whether it be of physical or mental 
origin, when depressing events occur. For this reason 
poets, who are what is called " highly strung," are par- 
ticularly subject to melancholy, as were Chatterton and 
Edgar Allen Poe. In sane persons such melancholy is 
of short duration, does not impair the reasoning power, 
does not greatly interfere with self-control, or with the 
general nutrition of the body. 

As each one in life experiences sudden shocks, griefs, 
fears, and apprehensions, which in the sane are reasoned 
with and met with whatever mental powers they possess, 
so in the unfortunate man or woman about to become 
the victim of insanity simple melancholia not rarely 
originates in the normal emotions of sorrow or in reason- 
able apprehension of coming evil. In the ordinary course 
of events this misery becomes abated, the pangs of grief 
are mitigated, consolation is felt, and new interests and 
aspirations are awakened. Sometimes, however, this is 
not so. The grief is protracted and deepened, and will 
not be comforted. A state of unyielding moody misery 

231 



232 THE VARIETIES OF INSANITY 

becomes habitual — in fact, simple melancholia is es- 
tablished, and medical treatment is requisite. 

It is not always easy to distinguish melancholia from 
ordinary depression in healthy individuals. If the ex- 
citing cause is slight, if the effect in the individual is 
unusually intense and prolonged, if the depression in- 
creases with time, if it continues after removal of the 
primary cause of depression, then the probability is 
increased that we are dealing with an abnormal state of 
feeling. The painful state of feeling that occurs in 
healthy individuals is not general, and may still be in- 
fluenced in a certain measure by pleasant impressions, 
while, on the contrary, abnormal painful depression of 
melancholia changes even pleasant feelings into those 
of an opposite character, and recognises only variations 
of intensity of misery. 

Depression is a symptom common to a great variety 
of mental diseases, but by melancholia proper is meant 
a simple affective insanity in persons not necessarily 
burdened with neuropathic heredity, characterised by 
vague feelings of anxiety, and mental pain which is 
excessive, out of all adequate proportion to its cause and 
accompanied by a more or less well-defined inhibition 
of the mental activities. Women are more subject to 
attacks of melancholia than men, and this is especially 
true in early and advanced life. 

Simple melancholia is by far the commonest form of 
mental disorder, and shows less departure from normality 
than any other form of insanity. The melancholic 
patient realises that he is sick in mind. Owing to the 
insight into his condition, which is absent in most other 
forms of insanity, and to the fact that his intellect is 
not confused, he can give reliable help. 

The beginnings of melancholia are usually insidious, 
or at least gradual. The physical accompaniments are 
the same as we see in mental agitation in the sane — 
namely, loss of sleep and appetite, and failure of general 
nutrition. The patient generally complains of insomnia ; 
the sleep is broken by unpleasant dreams, and is un- 
refreshing. The subject is often acutely conscientious, and 
distresses himself needlessly with worries about business 
or family matters ; there are spells of more or less intense 



STATES OF MENTAL DEPRESSION 233 

depression, and often the unreasonableness of these is 
appreciated by the individual, but he cannot rid himself 
of his morbid feelings. 

Of course, the patients may have always been appre- 
hensive, grave, reserved, and highly conscientious, and 
only grown worse, in which case signs of bodily illness or 
debility due to defective nutrition, over-work, or intoxica- 
tions of various kinds, may be looked for and treated. In 
others, however, there has been no exceptional apprehen- 
sion before, and there is not the least cause for it now, 
and yet it has lasted for months and is getting severer. 

Such a person is insane because his depression is 
disproportionate in its degree and duration to the grief 
or calamity with which it is connected, the depression is 
more intense at one time than another without any 
apparent cause, and is intractable and independent of 
external influences. In ordinary grief the mind may be 
diverted for a time from the contemplation of its misery, 
and is not incapable of amusement nor of social pleasure ; 
but in melancholia the attention is riveted to painful 
impressions, and cannot be attracted by outward 
allurements. Moreover, the voluntary power is impaired 
so that the patient is deprived of resolution and the 
power of decision. His will is paralysed, and he may be 
so inactive that he will not move unless obliged to do so. 
There is a disinclination for work, a want of interest in 
former avocations and recreations ; there is an indifference 
in the ordinary interests of life, and a desire for seclusion. 
Amusements are a nuisance to him. He finds even 
letter- writing a bore, and is often irritable to those about 
him in a way he never was previously. This retardation 
applies to all actions ; he moves slowly, hesitates over 
everything, and appears to think slowly. He can find 
no pleasure in anything, nor can he be touched by the 
misfortunes of others, his own distress absorbing his 
whole attention. 

Later, as this apathy grows, the patient becomes un- 
tidy in his habits, he loses all care for his personal ap- 
pearance, the world presents to his jaundiced mind an 
appearance that is dark and dismal, and no compensation 
is afforded by attempts at work or in the pursuit of 
pleasure ; everything has become irksome. 



234 THE VARIETIES OF INSANITY 

The intellect remains intact, but the ideas seem unable 
to flow, and as every physical act augments the psychical 
pain, the patient avoids all occupations, becomes inert, 
irresolute, unable to make the simplest decision, and 
broods over his own sadness. He may be able to 
reason acutely enough in regard to matters with 
which he is familiar, and may, with a sort of 
spasmodic energy, conduct himself with credit in 
a dispute or an argument of short duration; but 
he is incapable of long-sustained mental effort, and un- 
equal to the task of investigating subjects new to him. 
Indeed, the mental concentration necessary to such 
pursuits is rendered impossible by the pre-occupation 
of his mind. The patient in this state cannot give ex- 
pression to his feelings ; there is often considerable 
delay in replying to questions, or a faint murmur of 
reply is all that is heard. 

So-called psychical blindness, a visual disturbance, in 
which the capacity for seeing and perceiving objects is 
preserved, but in which jthe capability of recognising 
them, save through the other senses* is lost, is not an 
uncommon symptom. 

Indeed, the fundamental characteristics of melancholia 
are passivity and inertia. This mental inhibition is an 
important factor on account of the incapacity of these 
patients to reach beyond one line of thought, the pa- 
tients recognising only too clearly their altered state. 

Owing to the sluggishness of thought a feeling of 
monotony necessarily arises which is the principal com- 
plaint of many melancholiacs. 

The paralysis of the feelings in melancholia is of special 
importance. It is expressed in indifference toward those 
things which are otherwise held to be of the highest 
importance — religion, family, occupation, friends, and 
social duties. The patients are painfully depressed by 
this, and begin to doubt whether they are human beings, 
because they no longer feel as human beings feel. The 
want of religious support and the comfort afforded in 
prayer is felt to be especially painful. 

The inactivity of mental processes appears to extend 
to the bodily functions. Digestion seems to be delayed, 
and constipation is almost invariably present. 



STATES OF MENTAL DEPRESSION 235 

This mental state is almost the complete antithesis 
to mania, in which we find — in place of mental inhibition 
with self-depreciation — restless activity of mind, an 
apparent acceleration of the association of ideas, with 
exaltation. Although in this uncomplicated form of 
melancholia the individual shows no tendency to imbibe 
actual delusions, he constantly exaggerates the nature 
and consequences of his own acts and those of others. 
Thus the patient may refer to the sins of his youth as the 
cause of the apprehension, but it is clear that, even if 
they were really committed, they did not particularly 
disturb him before his illness ; his conscience has only 
awakened now. If he has committed errors in his busi- 
ness, though they may really have been of no great 
consequence, he brings himself to the belief, or at least 
the fear, that immediate financial ruin is staring him in 
the face. You may show him his bankbook, you may 
bring him his business acounts which tell of prosperity 
and wealth, but this has no effect whatever in dispelling 
his fancies. If he has money invested, or commercial or 
other transactions in hand, he is certain the one will be 
lost and the others will result unfavourably. He is, 
therefore, supremely unhappy, and the state of his mind 
is exhibited in every feature of his countenance and 
shown in every gesture that he makes. He weeps, sobs, 
wrings his hands, groans, sighs, and laments in the most 
sorrowful accents the cruel fate which has come upon 
him. He wishes he were dead ; the grave would be a. 
relief ; and yet he expresses the belief that beyond this 
life there are greater sorrows in store for him. 

These feelings of unworthiness are not delusions—in- 
deed there is no actual intellectual defect at this stage ; 
it is simply an emotional disorder. The feeling of wrong- 
doing or guilt becomes more definite later, and is the 
origin of the self-accusations that form so frequent and 
prominent a characteristic of the fully developed dis- 
order. 

In the mild stage of melancholia there may be a 
tendency to suicide, but this is the result of reflection, by 
which he arrives at the conclusion that death would be a 
relief. If he does not attempt self-destruction, it is 
because of his doubts as to the future, or because he lacks 



236 THE VARIETIES OF INSANITY 

the physical courage necessary to the act, or because of 
the sorrow that his family would feel, or of some other 
rational motive. 



MELANCHOLIA WITH DELUSIONS 

After the incipient stage is passed and full-fledged 
melancholia has taken its place, the symptoms have 
changed. The mental pain becomes much more intense ; 
it passes into an extreme mental neuralgia. The vague 
depression or fear which has been held as it were in solu- 
tion in the mind gradually crystallises into certain de- 
lusional forms or beliefs. The predominant picture now 
is fixed intense depression, with a decidedly delusive 
tendency ; the patient's judgment and mental powers 
have given way ; he surrenders to his morbid feelings ; 
his whole mind is concentrated on his mental distress, 
which he shows in his facial expression and bodily atti- 
tudes. Apprehension and fear have now passed into 
dead certainty, and ideas that could before be corrected 
by the intellect are now no longer under its sway, since 
the reasoning power is in abeyance. 

During the acuter stages of the disease hallucinations 
and illusions may become common, and when they occur 
they exercise a marked effect on the patient. 

Hardly two patients present the same series of delu- 
sions, and the only classification available is into psychical 
delusions, from perversions of the intellect, and physical 
delusions, those appertaining to disordered bodily func- 
tions. The delusions are so numerous that any attempted 
list must be of necessity incomplete. They are always 
of a painful nature. They may take the form of painful 
ideas of culpability. The patients accuse themselves of 
having caused their own illness, of having ruined and 
dishonoured their friends, of having brought trouble upon 
other people through misdemeanours or imaginary crimes 
which may be of the most heinous nature or childishly 
unimportant, but which are always made to bear a 
definite causal relation to their own affection or to the 
troubles of other people. The vague feeling of having 
done something wrong has developed into a belief, a 
conviction that his soul is lost, that all the world knows 



STATES OF MENTAL DEPRESSION 237 

his unworthiness ; he finds in the memories of his past 
life what is to him ample proof of his delusions, and in 
what he observes in those around him evidence that they 
also share his knowledge. Everything is wrong with 
him, and he has wronged those nearest and dearest to 
him ; his punishment has already begun upon earth, 
and is to continue through eternity ; he is incapable of 
ever feeling pleasure or comfort again. With this comes 
the idea of suicide and self-torture. 

With all this and a certain slowness and embarrass- 
ment of thought, there may be in all matters outside of 
his morbid feelings and delusions quite a normal state 
of intellection, and sometimes brief diversions of the 
ideas may be brought about even in pronounced melan- 
cholia. 

Sometimes the patients have indefinite fears of im- 
pending evil, causing them great agitation. It is a fear 
of something, but they do not know what. If they seek 
for an explanation, one variety will explain their fear by 
their sins and misconduct — that is, by self-accusation as 
just described ; others seek the cause in external events 
'and accuse people of wishing them harm. They may 
imagine that they have committed sins or crimes, that 
they are the cause of all the misery in the world, for which 
various forms of torture are being prepared as a punish- 
ment ; or they may believe themselves to be the subject 
of persecution on the part of other people. However, 
unlike the true persecution-maniac, they never retaliate 
against their persecutors, but always accept their sup- 
posed injuries as a more or less just retribution on 
account of their imaginary misdemeanours. 

Illusions and hallucinations of sight, hearing, and 
taste make their appearance. Long rows of horrible 
characters may pass in endless procession before the 
strained and wearied eyes ; pictures of a vividness 
scarcely ever realised in normal life are presented, in which 
the most horrible acts are being committed by personages 
of frightful mien. The patient may imagine his food 
has been poisoned, or that it is rotten or otherwise unfit 
for use, and hence there is an obstinate refusal to eat. 
Or he may think he hears the voice of God commanding 
him to kill his wife and children, and that to disobey 



238 THE VARIETIES OF INSANITY 

Him would be a heinous sin. The voices frequently 
suggest the desirability of suicide, and as the patients 
very often believe that the voices are authoritative, 
coming directly from the Deity, from the Devil, or from 
some supernatural agency which possesses them, it may 
be easily imagined that the influence of the hallucination 
is often imperative. 

The defmiteness of the delusions varies much in 
different cases. In some patients they are not expressed 
at all, but the predominance of painful and false ideas 
may always be inferred from the patient's attitude and 
manner. In the quieter cases the patients are immobile, 
passive, and irresponsive ; in the agitated cases the 
patients become restless, are unable to remain in one 
position or to sit down for any length of time ; they rub 
their hands mechanically, tear their hair out or destroy 
their clothes, or give expression to cries and ejaculations 
of a painful nature. 

The tendency to silence is often very strongly marked, 
but it may alternate with periods of great loquacity. 
During a paroxysm of taciturnity the patient appears 
to be in a state of active thought as seen by his gestures, 
but if spoken to he preserves an obstinate silence. When 
disposed to talk, he rambles from one subject to another ; 
but all his words are expressive of the delusions in his 
mind, of the evil, the misfortune, the degradation, to 
which he is being subjected. 

In Hypochondriacal Melancholia the delusions originate 
in an uneasiness of the functions of the body, the stomach 
or bowels, respiratory, circulatory, or other organs. 
Gradually the attention becomes concentrated thereon, 
until at last the patient is convinced that he is 
afflicted with some serious and extraordinary disease, 
that some of his organs are absent or displaced, or that 
an organic function has been permanently arrested. 

Such victims of hypochondriacal melancholia will tell 
one that they have no stomach, will present for examina- 
tion a limb, which, despite its obviously well-nourished 
condition, is cited as evidence that the body is drying 
up or mortifying ; or again, they will assert that they have 
not slept for months and cannot last long, that they 
are undergo ingstarvation, that their bowels are obstructed, 



STATES OF MENTAL DEPRESSION 239 

and so on in endless variety. Patients of this class are 
abject pictures of misery, wholly absorbed in their own 
fancied complaints. Sometimes they really have some 
slight ailment, which they exaggerate to the extreme 
and ridiculous. 

Melancholia with stupor is of gradual development, 
either as a primary disease or as sequence of some other 
form of insanity. Again, these patients are under the 
influence of extreme fear, and have terrible hallucinations 
of sight and hearing. They present a distressing appear- 
ance, sitting motionless with hands clasped and head 
bent forward, the eyes closed or staring vacantly or fixed 
upon the floor. If spoken to, they do not answer or 
even give any sign that they have heard. The patients 
are entirely sunk in the contemplation of their own 
calamities, apparently entirely oblivious of what is 
transpiring around them, and absolutely without will- 
power to rouse themselves out of their stuporous 
condition. If they do speak, they are very apt 
to utter some irrelevant word or sentence, and they 
may go on repeating it for hours at a time, day 
after day. Sometimes, when an attempt is made to 
extend their contracted limbs, a strong resistance is 
encountered, and if they are placed in a forced position 
they remain in it indefinitely. 

Catalepsy is a condition in which a patient remains 
like a wax-figure in one position, without ever volun- 
tarily moving ; and Tetany, a condition in which the 
muscles contract and offer enormous resistance when 
the patient is taken hold of. Both occur in severe 
melancholia. 

The cutaneous sensibility of such patients is often 
greatly diminished, both to sensations of touch and of 
pain. Their expression is either one of absolute apathy 
or vacancy, or is indicative of astonishment or terror. 
At times tears flow from their eyes, and they exhibit 
all the evidences of grief. 

Another variety of melancholia is just the opposite 
to the last described, and instead of passivity shows 
motor agitation, incessant movement, together with 
the appearance of an agonised frame of mind. In 
this form, the agitated melancholia, the intellect is 



240 THE VARIETIES OF INSANITY 

more involved and the whole aspect graver. Motion 
is incessant, and is accompanied by tearing the hair, 
disarrangement of the clothing, striking the head with 
the hands, sobbing, and the repeated ejaculation of some 
fixed phrase as " I am damned ! " "I am lost ! " 

The motor excitement is not like that in " mania," 
but quite different. The movements in melancholia, 
like the ideas, are monotonous and restricted, and con- 
sist of such movements as wringing the hands, uttering 
cries and phrases, walking up and down the room, or 
pulling, rubbing, or striking the scalp or some other 
part. The movements are purposive and rhythmical. 
They are repeated interminably, and the patient seems 
hardly conscious of them. 

When melancholia tends to become chronic as a terminal 
condition of the acuter form, the symptoms become 
modified, and although the patients retain their delusions 
and a certain degree of mental depression, the former 
remain as a sort of habit of mind, and the latter loses 
much of its painful character. The mind becomes 
apathetic, and the general mental condition is indicative 
of enfeeblement, with impairment of intelligence and 
of feeling. 



SUICIDE 

That suicide is not always the result of insanity we 
must infer from the calm and deliberate manner in 
which it has been perpetrated. This act has frequently 
been the result of rational motives, which can be well 
appreciated by sane persons as not altogether devoid of 
influence, of motives well weighed, of deliberate, calm 
determination of the will. It results from a desire, not 
in itself contrary to nature or reason, to escape from 
anticipated evils, from the sufferings of life protracted 
under circumstances which promise only shame or 
misery and disappointment. 

The frequent practice of suicide in many countries, 
where it has been looked upon as in no way culpable 
or indicative of mental disorder, removes it from the 
class of those anomalous and unaccountable acts de- 



STATES OF MENTAL DEPRESSION 241 

pending on insane impulses. Pliny terms it the greatest 
privilege that the gods have left in the power of men 
amid the calamities of human life. At Ceos, the country 
of Simonides, it is said to have been a popular maxim 
that every citizen ought to destroy himself when he 
attained the age of sixty, and it was supposed shameful 
to survive the period when a man became unable to serve 
the commonwealth. Among the ancient Romans, as 
we learn from Tacitus and other writers, suicide was the 
general result, among nobles, after falling into misfortune 
or public disgrace or under the displeasure of the Emperor. 
Among the ancients, suicide was thought by no means 
criminal or even despicable, and the sentiment of 
Socrates, who censured it, is recorded as something 
novel and remarkable. A similar observation may apply 
to some countries in the Far East, where a public officer, 
who has fallen into disgrace, is almost expected to 
terminate his career by self-destruction. 

On the other hand, there is no want of evidence that 
this act is, for the most part, the result of mental disease. 

Self-preservation as the first law of animal life is so 
obviously true that the deduction that to act contrary 
to this is abnormal would appear to be self-evident. 
Whether this abnormality is of the nature of insanity 
has, however, to be considered. / 

Nearly every human being suffers at some period of 
life from troubles and anxieties much more severe than 
those which ordinarily lead to suicide, so that the per- 
sons committing it clearly differ from the normal. In 
that sense the lay opinion is right that self-killing is the 
outcome of mental disorder. 

The principle upon which the English Law punishes 
unsuccessful suicides is because it regards the act as self- 
murder, and murder is a criminal act. 

As a matter of fact most men are guilty of suicide. Man 
does not die — he kills himself. Every one — unless acci- 
dentally killed — commits suicide, either quickly or slowly, 
voluntarily or involuntarily, openly or covertly. Many 
men dig their graves with their teeth, others drown them- 
selves in drink, a few perish from overwork, more kill 
themselves with worry, whilst a very small fraction adopt 
more obvious, though not more erf ectual, means of ter- 

16 



242 THE VARIETIES OF INSANITY 

minating their existence on this planet. But whether 
performed at one stroke or prolonged over a period of 
years, the suicidal process is the usual method of ex- 
tinguishing life, and will continue so to be until clearer 
conceptions of what is meant by Health and the means 
for its preservation obtain general recognition. 

It is difficult to say when a patient may begin to be 
suicidal. 

At least 75 per cent, of all cases of suicides manifest 
some time before the fatal act a gloomy anxious temper. 
Some men at the slightest misfortune fall into despair, 
and think life no longer worth living. 

Undoubtedly everything that has produced a distaste 
for life or reduces a man to extreme despair may become 
a cause of suicide. Loss of fortune or of honour, the 
prospect of a cruel or ignominious death, the destruction 
of domestic happiness, want of strength to support phy- 
sical or moral ills, sometimes even the contagion of other 
examples of suicide, very often a miserable hereditary 
constitution, and many other circumstances may deter- 
mine an individual to take his own life. 

The patient finds no longer satisfaction in his usual 
pursuits and occupations, becomes restless, sleepless at 
night, or has his sleep disturbed by disquieting dreams, 
and so on. He becomes an annoyance to his immediate 
surroundings, then imagines that he is neglected, treated 
unjustly, or is despised, or else he thinks himself a 
burden to others, and does not communicate to them 
his desperate situation. Friends are often surprised at 
the rational, well-planned measures of these patients for 
the accomplishment of their purpose, or at the sudden 
execution of their project, often-times directly after some 
kind of recreation. 

The causes ordinarily charged with determining suicide 
are only the exciting, but not the predisposing ones. 
The storm has been brewing long before ; jealousy, un- 
successful love, loss of property, the clamours of creditors, 
the tortures of conscience, and all other motives have, 
generally speaking, only given the final thrust at an edifice 
whose ruin has been long impending. There are daily 
millions of people who bear with comparative equanimity 
disappointments, loss of wealth, loss of husband, wife, 



STATES OF MENTAL DEPRESSION 243 

children, or friends, of health, character, or social position. 
They do not dream of suicide. One man has a habit of 
thinking which casts a shade of gloom over everything he 
sees ; while another, of a happier mode of thought, perceives 
the sunshine behind the clouds, even when these for the 
moment conceal it. It is a particular predisposition 
that makes the man who has committed a crime end his 
life, rather than be convicted and reform afterwards. 
The genuine criminal does not seek death ; the love of 
life is a distinguishing characteristic of convicts. 

Suicidal impulses occur in neurasthenia (Chapter XVI), 
but they are recognised as unreasonable, are deplored 
and feared, and are fought against so long as possible. 
Suicide is easily wished for, and the opportunities for it 
are sought in melancholia, hence all cases of melancho- 
lia, however slight, should be treated as suicidal, and 
every precaution should be taken. To the melancholic 
patient death is a " relief. " It terminates unendurable 
suffering. 

Some will commit the act, or attempt it, when only a 
very moderate degree of depression has been noticed. 
But since in this milder form of melancholia the patients 
possess the full command of their reasoning powers, as 
well as the power of fixing the attention upon any definite 
act, they are capable of planning with considerable skill 
and detail the most effective method of ending their own 
existence. 

In the severer forms suicide is no doubt prompted by 
the mental sufferings and frequently suggested by hallu- 
cinations, and a considerable number of melancholies 
undoubtedly commit suicide impulsively. 

Suicide is attempted sometimes by children at puberty 
from loss of interest in life, or fear of punishment in 
highly sensitive children, and is always premeditated. 
Suicide is also common in senile dementia (Chapter 
XXII), and may be attempted by women in the insanity 
after childbirth as a direct consequence of frightful 
hallucinations (Chapter XXIV). 

On the other hand some insane cling to life. The general 
paralytic (Chapter XXII), reduced to the lowest depths of 
physical and moral degradation, manifests a remarkable 
satisfaction in being in the world, and would spend all 



244 THE VARIETIES OF INSANITY 

the small amount of energy he possesses in defending 
his existence, if it should be threatened. 

Persons suffering from delusions of persecution often 
commit suicide ; but this is not the same as suicide arising 
from melancholia. In the latter the patient thinks 
life no longer worth living ; he contemplates death, and 
may prepare for it. In the former the patient need not 
reflect on death at all ; he simply tries to escape from his 
persecutors. If he happens to be on level ground, no 
harm need follow ; if he is on a fifth-floor corridor and 
he can get out at the window, he may make an attempt 
to do so, with the inevitable consequences ; but it cannot 
be said that he is conscious of the fatal result, nor that 
he seeks it. 



CHAPTER XX 

PERIODIC ATTACKS OF INSANITY 

PERIODIC MELANCHOLIA 

Attacks of melancholia may occur periodically, but are 
usually not serious and of short duration, not exceeding 
two months, and the attacks disappear rapidly. The 
depression takes as a rule such a mild form that some 
patients can almost completely hide their suffering from 
strangers, and at all events make an earnest effort to 
overcome it. They are generally free from delusions. 
In the mildest form of the affliction there may be nothing 
more than a feeling of mental distress or sorrow, with 
inability to pursue the ordinary duties or business. 

PERIODIC MANIA 

Attacks of mania may become periodic. Whereas 
repetitions of melancholia may be sometimes accounted 
for by the delicacy of the patient's nervous organisation, 
his sensitive emotions, and the shocks and misfortunes 
he has suffered, periodic mania must be regarded as a 
constitutional disorder. 

The manifestations of periodic mania assume a great 
variety of forms. Occasionally there is a transitory 
intellectual perversion, fantastic ideas, religious mysti- 
cism, spiritualistic superstition, and sometimes even 
systematised delusions ; but frequently the intellect re- 
mains quite undisturbed, and we get only moral perversion, 
dipsomania, criminal conduct, or immoral excesses. 

ALTERNATE STATES OF EXCITATION AND DE- 
PRESSION. MANIC-DEPRESSIVE INSANITY. 
CIRCULAR INSANITY 

Not only can mania or melancholia occur periodically, 
but states of depression and excitement may follow each 

245 



246 THE VARIETIES OF INSANITY 

other alternately, and be succeeded by a normal period 
of varying length ; or maniacal-depressive phases may 
occur in one attack. 

Those who suffer from this form of insanity possess 
in reality two personalities which stand in perfect contrast 
to each other. Even the appearance of the patient is 
transformed so as to be almost unrecognisable. 

The disease is generally developed upon the ground- 
work of an inherited defect, either nervous or mental. 
There are normal people who spend their lives in a see-saw 
between depression and pleasurable exaltation. Such 
individuals are either gloomy, easily irritated, or pro- 
foundly depressed by the most trivial incidents. At 
other times they are joyous, easily excited, run eagerly 
after pleasure they would shun in the other stage, but 
withal are reasonable, perfectly coherent in thought and 
action, and in no way overstep the physiological limit of 
sanity. 

A consideration of these alterations within physiological 
limits, in the daily humour of many persons, enables us 
to understand more clearly the forms of insanity of the 
periodic type. When upon an ordinary unstable brain — 
unstable in the sense that the mental equilibrium is de- 
ficient — there is brought to bear a strain such as belongs 
to the attainment of puberty and adolescence when 
accompanied by some disaster or failure, the physiological 
boundary is quickly overstepped. The person becomes 
affected by one or other of the forms of the psychoses, 
depression or exaltation, and now the moods, cravings, 
and tempers become dominant. 

In the depressed stages the patient gets " low-spirited." 
He begins by losing interest in his surroundings, he can 
no longer apply himself to routine-work ; he finds diffi- 
culty in keeping the run of conversation or in keeping 
his thoughts on what he reads. He is not apprehensive 
and has no delusions, though they may develop later ; 
only utterance of speech and all actions of the will are 
difficult. He differs therefore from the melancholic 
insane through the strong impediment of volition and 
the absence of apprehensive restlessness. 

The patient is indisposed to either physical or mental 
exertion, he shuns the companionship of others, is averse 



PERIODIC ATTACKS OF INSANITY 247 

to speaking/frequently remaining silent for hours, and if 
forced to respond to questions put to him, he does so in 
the fewest possible words, and without change of counte- 
nance. When he talks, it is in regard to his personal 
condition, his despair, his dreadful thoughts of the past 
and the future. His duties are neglected, for he has not 
the force to perform them, even if he felt the obligation 
to do so ; in fact, the most exciting events do not engage 
his attention. He neglects his person, and is regardless 
of those proprieties of life which are essential to the 
comfort of sane persons. 

Just as in ordinary melancholia, the patient is conscious 
of his depression, and recognises that he feels no senti- 
ment or affection for those formerly dear to him ; he 
has lost feeling for everything, and even the death of 
persons nearest to him leaves him absolutely indifferent. 
The face has the look of sadness or weariness, the features 
are contracted, the brows frown, and the eyes, sad and 
full of despair, generally look down to the ground. 

When the melancholic state follows the maniacal state, 
the patient recognises that in the earlier state he was 
insane, and tries to explain his erratic conduct of that 
period. 

Sometimes the melancholic state becomes complicated 
by delusions of ruin, incapacity, and culpability. There 
are fear and uneasiness without mobility. Sometimes 
delusions of suspicion based on hallucinations of hearing 
develop, when there may be refusal of food. Lastly, the 
patient gets into a stuporous condition with still more 
frightful delusions and hallucinations. 

Sometimes, quite suddenly, the patient changes, be- 
comes bright, and looks ten years younger. The change 
of the emotions is so rapid at times that a patient 
may go to bed a melancholiac and rise a maniac, so 
that it is impossible to say whether he is a melancholic 
maniac or a maniacal melancholiac. 

The state of agitation and excitement has set in. The 
cardinal symptoms of this, the maniacal state, are : 
rapidity of ideas, facility and ready flow of language, 
impulses to continued action, though the work accom- 
plished may be inconsiderable, and unnaturally high 
spirits, without the presence of hallucinations, delusions, 



248 THE VARIETIES OF INSANITY 

or mental clouding, or at least these are only transitory. 
Just as in hypomania, the patients are capable of reasoning 
correctly, of observing what goes on around them. There 
is an exaltation of the mental functions, the memory 
becomes hyperactive, insignificant events are recalled 
with facility, and poems and literary passages may be 
repeated which they believed had faded from their 
memory. Such patients speak and write incessantly. 
They talk " big " like the hypomaniacs (Chapter XVIII), 
but have not quite the same self-assurance. The fact that 
they know nothing of a subject is no bar to their conversing 
about it. At the same time it may be noticed that they 
have lost the sense of proportion and of the fitness of 
what ought to be said or written. This excitement is 
of a pleasurable nature, and is mingled with feelings of 
self-satisfaction and confidence. There is a lack of 
judgment preventing them from gauging the consequences 
of their actions. Natural cautiousness is forgotten, new 
projects beyond the limits of common sense are under- 
taken, speculations are indulged in, journeys without 
object are begun, love affairs — before in the background 
— are taken up and pursued with avidity or new ones 
are sought after. 

They also lose their natural affection for their friends 
and relatives, whom they neglect, while they are often 
familiar and confidential with utter strangers. They are 
frequently untruthful, and, if unable to carry their points 
by fair means, they do not hesitate to lie and cheat to effect 
their purposes against those whom they imagine to be 
hostile to them. They are therefore apt to be con- 
stantly in dispute. 

Persons who have previously followed a quiet mode of 
life seek frivolous society and the pleasures of the drink- 
ing-saloon, and, in fact, give way to excesses which are 
beyond the limits of propriety or decency. 

Conjoined with the excess of mental activity there is 
a corresponding condition of the muscular system. 
Patients thus affected are continually in motion. Rest 
is as painful to them as action is to those who are passing 
through the stage of depression. They sleep but little, 
yet do not appear to suffer from insomnia. They have 
no time for resting, they have no time for proper meals 



PERIODIC ATTACKS OF INSANITY 249 

at regular intervals, being driven about by constantly 
changing impulses or projects. Kleptomania, dipso- 
mania, and erotomania are common in this state, and 
sometimes ideas of exaltation occur. 

From a forensic point of view the responsibility and 
culpability of such patients are often a question for the 
expert. During the period of excitement the patient 
may have committed all sorts of criminal actions, brought 
unjust accusations, published gross libels, may have dam- 
aged the fortune or reputation of his family, or may have 
made disputable wills, etc. 

In some patients the disease commences with de- 
pression, changing into agitation, and is then followed 
by a normal period. In others the disease commences 
with excitement, is followed by a period of depression, 
frequently of a mild form, as if brooding over the follies 
of the maniacal attack, and afterwards a period of normal 
life occurs. 

The convalescence of such patients is frequently 
marked by a numb feeling of the head. For a time all 
such patients recover, but there is always a tendency to 
recurrence of the disease, since it is based on some heredi- 
tary defect. It is therefore essentially chronic, but 
dementia comes on very late, if at all ; much more fre- 
quently the disease is transformed into another variety 
of insanity, mania, or melancholia, which ultimately 
predominates. 



CHAPTER XXI 

PROGRESSIVE INSANITY WITH SYSTEM ATI SED 

DELUSIONS 

PARANOIA 

This disease is a chronic mental affection, characterised 
by delusions, working on a tainted constitution, which 
tend to become fixed and systematised, and in which 
various hallucinations are common. The important 
point of the disease does not lie, as in melancholia and 
mania, in primary emotional and psychomotor disturb- 
ances, but in the disturbances in the ideational sphere, 
in the delusions and in the absence of critical power. 

The hereditarily ill-balanced brain shows itself ab 
initio in a peculiar temperament, a ready excitability, a 
mistrustful character, with distaste for companionship, 
and melancholic tendencies. As a rule the disease is 
seen in persons who are bright and clever, but have 
perhaps been narrow-minded and always considered a 
little " queer." Suspiciousness is the characteristic of 
this disease, hence it is called Paranoia, from the Greek 
verb paranoio, meaning " to understand wrongly." 

The disease commences often at the age of puberty, 
never abruptly, with malaise and uncomfortable sensa- 
tions, a hypochondriacal depression, which makes the 
patient moody and introspective, followed by a stage of 
subjective analysis. They attach importance to the most 
trivial symptoms, analysing their own thoughts and 
feelings, and worry over them in secret. 

The patients begin to suspect that there is something 
peculiar in their personal appearance which unduly 
attracts the attention of other people. From such ideas 
the transition to the belief that they are stared at for 

250 



INSANITY WITH SYSTEM ATI SED DELUSIONS 251 

some sinister purpose is very easy, that they are des- 
pised, or distrusted, or socially tabooed. They feel they 
are not understood, and misinterpret the actions of those 
around them. They form suspicions, which are in the 
first place well founded. It is from the frequent justifi- 
able suspicions, when the subject is in a condition of 
irritable weakness, that ill-founded suspicion arises. 
Sometimes the suspicion arises from unhappiness, for 
which, instead of reproaching themselves as the melan- 
cholic do, they reproach others. 

Often the delusions are created consciously by de- 
generates in whom judgment and intellect are weakened 
by natural defect. Outside the field of his delusions the 
patient may be clear mentally and have his reasoning 
powers unaffected. Such individuals are capable of 
considerable education, at times of brilliant acquire- 
ments, yet possessing a mental twist. They are often, 
at least in their own estimation, under-rated geniuses. 
Anyhow, they show unusual association of ideas, see 
things in new and strange relations, but are unable to make 
the new thoughts useful. If capable of inventions, they 
can make suggestions that more efficient doers can carry 
out; but, as a rule, most of their philosophising refers to 
the welfare of a class or a race. 

The patients retain full command of their powers of 
judgment, and in their better moments they succeed in 
ousting their strange thoughts and foolish fancies; 
but only temporarily, for they are sure to return with 
more persistence than ever. The subject goes about his 
ordinary business, and appears only odd in manner, or 
a little eccentric in certain ways for a long time before 
any one really recognises his condition or suspects that 
anything whatever is seriously amiss. In this way the 
patient's life becomes a constant struggle between hesita- 
ting doubt of his false ideas and the self-assertion of his 
better judgment. Gradually the struggle ends in favour of 
the disease, and the patient, losing self-control, may openly 
accuse people of staring at him or otherwise annoying him. 
When this condition is reached, he becomes extremely 
sensitive regarding the motives of other people. Even 
acts of kindness or affection may appear to him as insults, 
and silence itself is an offence. To these imaginations 



252 THE VARIETIES OF INSANITY 

the patient adds a review of his former life, persistently 
dwelling upon slight oversights and insults which he may 
have received until he becomes convinced that he has 
long been a victim of a systematic persecution. Little 
by little the misconceptions and false interpretations 
assume greater power ; doubt is strengthened by various 
accidental proofs ; snatches of overheard conversation 
now convey certainty. He now accepts his delusions as 
realities ; feels himself an object of persecution, though 
as yet he may not definitely attribute it to any indi- 
viduals. The person soon believes that the outer world 
has altered its relation to him ; everything is seen in an 
unfavourable light ; a spell which he has no will-energy 
to overcome is upon him ; everything is a burden. 

Hallucinations of hearing now commence, first vaguely 
as sounds or noises in the ears ; little by little the 
sounds resolve themselves into distinct voices, words 
and finally complete sentences and long conversa- 
tions are heard by the patient. These voices abuse 
and insult him, and sometimes he hears other voices 
raised in his defence. In the vast majority of these cases 
the voices are inimical ; they threaten his person, they 
slander him in every manner, or excite him to stab 
himself, or to commit suicide in some other way. One 
by one his actions are repeated aloud to him ; even his 
secret thoughts are filched from him and made audible. 
The voices pursue him continually ; in the roar of the 
street or in the stillness of the night equally are they 
heard. They follow him wherever he goes, disturbing his 
sleep by constant presence* 

It is under the persistent influence of hallucinations 
of hearing that the delusions become systematised. 
First, they are indefinite, but gradually the patient comes 
to believe that he is the victim of a conspiracy on the part 
of some public bodies, or secret societies, or even of 
supernatural agencies. Frequently the suspicions be- 
come directed against a particular person, who, being 
in complete ignorance of the patient's delusion and 
hatred, is off his guard, and thus does not perceive 
that he is in danger of being a victim of revenge. 

Later, hallucinations of taste and smell may cause the 
patient to think that attempts are being made to poison 



INSANITY WITH SYSTEM ATI SED DELUSIONS 253 

his food ; or that noxious vapours are injected into his 
bedroom, so that he carefully stuffs all the keyholes of 
the doors and any other opening. There may be also 
hallucinations of general sensibility, which he attributes 
to electricity, magnetism, wireless telegraphy, hypnotism, 
or other physical or spiritualistic agency. 

It is exceedingly rare for the patient to see his perse- 
cutors ; hallucinations of sight belong rather to the 
alcoholic than the paranoiac. The sensations come from 
behind the walls or through the ceiling, beyond the 
reach of the visual apparatus. From their invisibility 
the sufferer infers that he is the victim of the machinations 
of secret cliques, of nihilistic societies, of priests who 
have banded together for the purpose of tormenting him 
for their own ends. 

It is very exceptional for the hallucinations or de- 
lusions to take on an agreeable form, even temporarily ; 
in nearly every case they are painful or disagreeable. 
The irritation caused by the combination of hallucinations 
frequently gives rise to attacks of excitement. It is at 
this stage that the sufferers not infrequently fly from 
their imaginary persecutors to some place of supposed 
shelter or seek the aid of the police, and their insanity 
is then recognised. 

At first the wretched person quits his place of work 
under the belief that his associates taunt him, spy on all 
his acts, and are in league to drive him from their midst. 
A new field of labour is undertaken, and for a time all 
goes well ; the suspicious attitude, however, is main- 
tained, and it is not long before the same difficulties are 
experienced anew. He leaves and tries another place, 
and another, with the same result. Either he is afraid 
of his new-found friends after a few days or weeks, or 
he thinks that his former enemies can reach him in his 
new sphere. 

In this, the passive stage of their conduct, the patients 
are on the defensive toward the delusionally conceived 
external world. They avoid it, shut themselves up 
in their rooms and change their dwelling frequently. 
They cook their own food or live on raw eggs, 
treat themselves with antidotes, flee to foreign lands, 
or take other names in order to save * themselves 



254 THE VARIETIES OF INSANITY 

from their persecutors. Then the condition grows more 
and more painful, becoming unbearable. They change 
from their passive state ; but before they become danger- 
ous they usually give premonitory signals of the approach- 
ing storm, which, however, only too frequently remain 
unnoticed. They threaten their supposed persecutors 
and apply to the Courts for protection, until, sadly 
convinced that their efforts are vain, they are forced to 
defend themselves. At this stage the patient is extremely 
dangerous. 

It is at this stage that the innocent remark of a chance 
passer-by in the street or elsewhere may provoke a 
violent attack. When committed, the crime is rarely 
secret, but done openly before witnesses ; upon being 
seized, the aggressor justifies his act, and even gloats 
upon his success in removing one of his enemies. 

Whereas the melancholic accuses himself and searches 
within himself for reasons of his unhappiness, blaming 
his own sins from an excessive sense of conscientiousness, 
the paranoiac always blames others. It is their wicked- 
ness, their conspiracy, that makes him suffer. 

In some the mental powers now weaken. In others 
the persecutory ideas are eventually relieved by the rise 
into the sphere of consciousness of a delirium of an 
ambitious nature. This change in the personality is 
achieved either suddenly or gradually. The long perse- 
cution, together with the influence of the consoling 
voices, eventually give the patient the conception that 
he must be a person of some consequence, and has been 
persecuted from envy and jealousy because of his great 
mental endowments, his exalted position, his great 
wealth ; or delusions of a religious character, in which he 
is the world-saviour, a prophet, the special object of 
divine guidance, or that Providence has in view some 
secret mission for him to perform, and other delusions 
of a like nature are conceived in his disordered imagina- 
tion. 

In dream or half-sleep he is visited by supernatural or 
celestial personages, and possibility becomes certainty. 
Castles in Spain of the most improbable order fill the 
mind of the patient. Whatever false beliefs develop, 
they are persistently held, and are finally woven into a 



INSANITY WITH S Y STEM ATI SED DELUSIONS 255 

plausible system. A large number become inventors of 
complicated electrical and perpetual motion machines, 
the latter being a favourite subject for the exercise of 
their ingenuity ; or they invent firearms capable of 
being discharged a thousand times a minute. Some 
pose as reformers of society, and, having retained con- 
siderable power of logical thought, they may receive 
support until their delusions become too palpably 
absurd. Others, especially women, become religious 
devotees. They attend revival meetings, become excited, 
and are given to excesses of every kind, provided only 
that they can be indulged in under the cloak of 
religion. In the ardour of their fanaticism they slight 
tiousehold duties, neglect the members of their family, 
and forget meal times. In others there is erotic excite- 
ment. The gist of their delusions lies in an imaginary 
love which has been aroused in some person of the 
opposite sex, usually much above the patient's own social 
standing. As a consequence the desire is ordinarily of 
a secret, mysterious, and platonic character, the actual 
excitement finding vent in perversions of the natural 
instinct. They are usually society-shunning individuals, 
who look upon members of the opposite sex from a dis- 
tance, and form romantic ideas not only about them, 
but also of their own personal qualifications. All com- 
munications between them are necessarily in secret 
fashion. Every peculiar toilette, a chance word over- 
heard in passing, or the waving of a handkerchief have 
for such individuals a peculiarly romantic meaning. 

The grandiose ideas of the paranoiac, while equally as 
absurd as those of the general paralytic (Chapter XXII), 
differ from them inasmuch as they are of a fixed character, 
lasting over months and years, in contrast to the daily 
changing phantasmagoria of the paretic ; and in the partly 
retained intelligence of the paranoiac, who will attempt to 
defend his delusions and do so ably, while the paretic will 
state them as facts incapable of being disputed. 

Like the delusions of persecution, the delusions of 
ambition, pride, grandeur, power, and wealth are well 
defined, systematised, and definitely expressed. They 
gradually become more extravagant and mystic, and are 
the index of a further advance towards general mental 



256 THE VARIETIES OF INSANITY 

deterioration. When this stage is fully entered upon, 
the patient is generally less dangerous than when in the 
suspicious stage. 

As time elapses the hallucinations and proud and 
grandiose concepts become less and less prominent ; the 
wrath of the heavens is less frequently called down upon 
the head of any one so unfortunate as to contradict their 
statements ; the patients become quieter, somewhat 
apathetic, and, without being reduced to a condition of 
real dementia, have for ever lost the finer edge of their 
faculties evidenced during the troubled life of formeryears. 

The dementia in this disease is in the form of mental 
weakness of a mild kind and of intellectual degeneration, 
in which the patients retain their physical activity and 
their power of conversing in a rational manner on various 
subjects outside their delusions. But after a sustained 
conversation the patient's intellectual power will often 
be found to be exhausted, as shown by a tendency to 
wander from one subject to another, and a slight in- 
coherence of ideation. The disorder may be arrested 
at any stage. Many people who go through life as eccen- 
tric are possibly only aborted cases of paranoia, in whom 
the progress was checked in the early stage, and modified 
into a sort of crankiness and eccentricity, not pronounced 
enough for them to be commonly reckoned insane, but 
sufficient to make them noticeable as odd in behaviour 
and generally peculiar. They learn, however, to control 
their conduct and conceal their feelings to a very large 
extent, so that their real mental condition is not be- 
trayed, except by some habit of writing or speech when 
they are off their guard. 

Many assassins are men suffering from a form of 
paranoia, and, misguided by political obsessions, they 
think themselves persecuted and called upon to act the 
double role of judiciary and martyr, and to kill some 
great personage in the name of Liberty. 

Another well-marked variety is the litigious paranoia, 
the " Querulantenwahnsinn " of German authors. This 
form is usually first apparent in its subjects after some 
disappointment in a law-suit, which apparently forms the 
foundation for the building of delusions in the unstable 
mental organisation. 



INSANITY WITH SYSTEMATISED DELUSIONS 257 

These patients, notwithstanding the fact that they 
have good intelligence and complete lucidity, are so 
infatuated and devoid of moderation in the judgment of 
their own interests that they are unable to recognise the 
limitations imposed by the interests of others and by 
the precise terms of the law, and, interpreting the law 
in entire good faith, but with all sorts of bias, they 
plunge into ruinous and endless litigation. They are 
continually starting suits at law and demanding jus- 
tice. They never recognise the true relation of things, 
and they build up extensive delusions as to the rights 
they are deprived of and the wrongs they have suffered. 
The disorder may be considered as a special development 
of persecutory insanity, and is to some extent associated 
with the ordinary delusions of persecution. 

The disorder arises from colossal egotism which mis- 
conceives the rights of others, tends constantly to the 
assertion of personal rights, and reacts to an actual or 
supposed injury to personal interests in the most violent 
way. These patients early attract attention by their 
selfishness, irritability, their clamorous demands for 
justice, their infinite over-estimation of self ; and by 
reason of these characteristics they are constantly in 
conflict with others. Even when the intellectual en- 
dowment is above the average, there is a defect in the 
power of reproduction which makes facts reappear in 
consciousness in a distorted light. They take a curious 
pleasure in pettifogging legal processes. 

The exciting cause of the actual disease may be any 
lawsuit in which the individual has been defeated ; or 
may be the mere rejection of his assumed legal rights, 
which are, in reality, audacious assumptions. They fall 
into a passionate state of feeling as a result of the pre- 
sumed injury to themselves, and have only one purpose 
in view— the restoration of their imagined injured rights. 
Putting faith in their abnormal over-estimate of self 
and their own power, and without trust in lawyers owing 
to their abnormal suspicions, they devote themselves to 
the acquirement of knowledge of the law and legal 
procedure. Armed with these weapons they besiege the 
courts, write accusations, and make appeals wherever 
possible. 

17 



258 THE VARIETIES OF INSANITY 

With the repetition of lack of success in their efforts, 
and the consequent disappointment, they become more 
and more bitter, have less insight, and lose what remains 
of clearness of thought. Instead of recognising that 
their suit was unsuccessful because it was unjust, these 
patients, owing to their mistrust, seek the cause of their 
failure in partiality and venality of the judges ; and in 
harmless events they find proofs for this conviction, 
which becomes more and more fixed. Then the last 
restraints disappear. Their constantly more voluminous 
recriminations, requests, and denunciations are filled 
with invectives and insults to officials. They now look 
upon themselves as martyrs and dupes of the Law ; all 
legal procedure was only a parody of justice. With 
insane obstinacy and pettifogging logic these individuals 
now oppose not only justice, but the law which has given 
judgment against them. They refuse to pay fines, 
indemnities, taxes. They attack the officers of the Law 
and call the judges of the State thieves, scoundrels, and 
perjurers. They feel that they are in the state of war 
against suffering justice and its evil interpreters, as 
champions of right and morality, as martyrs of brutal 
force. 

Usually for a long time such patients are misunder- 
stood by the laity and punished, for in spite of the 
absence of insight into the foolishness and irrelevancy of 
their manner of action, they possess a remarkable amount 
of dialectic power and knowledge of law, and are excellent 
advocates of their affair, which unfortunately is of an 
insane kind. Hardly have they been punished than 
they commit again the same misdemeanours, which are, 
for the most part, insults to officials, disturbance of 
public order, and contempt of court. 

There are many people in the world who have grievances 
real and imaginery, and strong over-self-appreciation, 
yet who are not insane. Many genuine inventors, philo- 
sophers, artists, poets, and others, placed in unfavourable 
circumstances, may have been robbed of the fruits of 
their works by some unscrupulous person, or else may 
have failed to attract any attention and, in consequence, 
formed an unfavourable or delusionary view of the 
world, against which they take an antagonistic stand- 



INSANITY WITH SYSTEM ATI SED DELUSIONS 259 

point in consequence of their misfortune. Even the idea 
of conspiracy may not be totally unfounded, or at 
least an unreasonable suspicion. How often is an 
inventor or discoverer, who is more outspoken than 
is agreeable to established cliques, boycotted by the 
official authorities and official journals. His opponents 
might say that he over-estimates his own importance, 
or deny there is any such organised obstruction to the 
recognition of his work, and so the man might be held 
to be labouring under a delusion and suffering from a 
mental disorder, whereas, on the contrary, he may have 
a sounder and clearer brain than his critics, to hold his 
own in the face of adverse circumstances, as is often 
shown when ultimately success comes to him. But if 
he should be unable to hold out, and should find death 
preferable to the prolonged battle against organised 
deceit and hypocrisy, the verdict would be that he was 
insane. On the other hand, since only the highest 
quality of nervous structure is capable of the finest 
work, a man who has suffered in the manner described 
may really break down and then exaggerate his own worth 
and his grievances to such an extent that he becomes 
mentally deranged. It is only when the delusions are 
so extravagant that their absurdity would at once be 
gauged by persons of ordinary intelligence that we are 
justified in presuming insanity. 



CHAPTER XXII 
STATES OF MENTAL ENFEEBLEMENT 

GENERAL PARALYSIS, DEMENTIA PRECOX, PRIMARY 
DEMENTIA, AND SENILE INSANITY 

GENERAL PARALYSIS {DEMENTIA PARALYTICA) 

This is a very common disease of the nervous system, 
and particularly of the brain, occurring during the 
active periods of life, characterised on its psychic side 
by a usually marked and generally progressive dementia, 
ordinarily attended with an expansive emotional 
condition ; and on its physical side there are paresis, 
inco-ordination, and other phenomena. Unlike most 
mental disorders it is accompanied by gross changes 
in the brain, chiefly in the frontal region, which tend to 
produce more or less complete dementia, motor and 
sensory paralysis, and ultimately death. The mental 
phenomena by themselves do not constitute general 
paralysis ; the physical signs must be present as well. 
Because of the fact that the paralysis involves sooner 
or later nearly every muscle of the body it is called 
" general." This paralysis may show itself at the same 
time that the insanity is manifested ; it may precede the 
mental derangement or it may be subsequent thereto. 
The latter is much the more usual order. It is a hope- 
less disease, but there are prolonged remissions in certain 
cases. It is much more common in men than in women, 
and, although authorities vary in their views concerning 
its causation, it is coming to be pretty generally believed 
to be due to specific disease combined with physical and 
mental stress. The poison of syphilitic disease, the 
presence of which can be tested by the now famous 

260 



STATES OF MENTAL ENFEEBLEMENT 261 

discovery of Wassermann's reaction, has so exhausted 
the nerve cells and deprived them of their vitality 
that they succumb readily to degeneration on any 
unusual stress, and this degeneration is accelerated by 
auto-intoxication. 

The most suspicious of all the circumstances, which 
may indicate the inception of general paralysis, is a 
gradual but obvious alteration in the mental character- 
istics of the individual. In the great majority of cases 
changes in the character of the patient, as well as certain 
bodily symptoms, are observable by the people with 
whom he lives. 

A general state of exhilaration, different from the 
patient's ordinary manner and feeling, may exist for 
several months or even years before any more obvious 
symptoms make their appearance. No one, in his own 
opinion, was ever in a better state of health than he, 
no one more successful in business, no one happier than 
he. He does things which are not in accordance with 
his disposition or faculties of the mind as they have been 
previously manifested. He contracts friendships with 
persons whom every one is certain he would have avoided 
but for the change which is coming over him ; he makes 
investments such as no prudent man would make, or 
throws away his money on useless objects. Unnecessary 
purchases may also be among the first signs noticed. 
The multitudinous, extravagant, and impracticable busi- 
ness ventures in one formerly astute in these matters 
are often the first indications that lead his friends to 
surmise that the man is insane. 

At home he is irritable and loses his temper over 
trifles. He harasses in every way those who are about 
him, gives them impossible orders, and then abuses them 
if he is not at once obeyed ; he is whimsical at his meals, 
his likes and dislikes are changed without adequate 
reason, and he either eats and drinks voraciously or 
declares that nothing is cooked to suit him and rises from 
the table in a rage. At times he sheds tears over the 
veriest trifles, and often for no reason that he can allege. 
Sometimes a sudden outbreak of violence may be the 
first definite indication of aberration, but the budding 
paralytic is rarely vindictive. Although easily roused to 



262 THE VARIETIES OF INSANITY 

anger, he is easily calmed. Being in his own estimation 
superior to every one, he can afford to pity and forgive. 

But of all the prodromata, failure and decay of the 
moral sense are the most important, and are exemplified 
by acts of omission and commission against law, order, 
and propriety. He may perpetrate frauds of various 
kinds or pilfer whatever he can lay hands on, and without 
adopting the means of precaution which the common 
thief would use to prevent discovery. Moreover, the 
articles he steals are not in general of any use to him, 
and are thrown aside as soon as he has them in his 
possession. 

The idea of propriety in the everyday affairs of life 
seems to be lost, and the patient will commit all kinds 
of indecent and obscene acts under circumstances which 
are almost certain to result in detection and without 
appearing to be aware that he is doing anything unusual. 
He becomes regardless of his personal appearance, neg- 
lects to change his linen, appears in public half-dressed, 
and indulges in other similar conduct, when previously 
he has been noted for scrupulous attention to all matters 
of cleanliness or etiquette. His sexual excitement may 
result in rape and acts of indecency. The patients refer 
to what they have done and to the possibility of what 
they may achieve in the future in exaggerated language; 
but, except for effect, they very rarely embellish their 
statements with actual facts. Another feature often 
noted is a forgetfulness from one day to another of the 
ordinary duties and details of business or household 
affairs, which leads to acts inconsistent with former 
conduct and apathy to the ordinary claims of family or 
friends. In other cases, instead of overweening com- 
placency, the disease may commence with gloom and 
despondency, but the depression is only of short duration. 
There is always present a certain amount of mental weak- 
ness and confusion, a sign of the commencing dementia. 

As the disease becomes more fully established, the most 
prominent symptom is tremor of the lips and tongue, 
which causes an embarrassment of speech when the 
patient comes to pronounce a more than ordinarily diffi- 
cult word. The tremors gradually involve, besides the 
muscles of facial expression, those of the limbs, hence 



STATES OF MENTAL ENFEEBLEMENT 263 

writing and mechanical work, even to those formerly skilled 
in it, become difficult of execution. Peculiar anomalies 
of the pupils of the eyes are also present at this stage, 
chief of which are sluggishness and immobility to light. 
The deeper reflexes may be exaggerated or lost, and 
sensation may be deranged. 

These physical signs, together with the alteration in 
the whole character, are safe signs of general paralysis. 

With the increase of the physical weakness, the mental 
weakness gets also more pronounced. The patient will 
make astounding claims. He is stronger than Hercules, 
literally able to move mountains ; he can build bridges 
to the moon ; he has a million horses ; can make dia- 
monds by the bucketful. These exaggerations some- 
times continue until speech becomes unintelligible and 
the patient is too weak even to feed himself. 

His emotions too get very unstable, and he can be 
easily made to laugh or cry. At the same time a pathetic 
optimism continues. He feels '■' fine " or " first-rate " 
even to the last stage of the disease. 

As the disease still further progresses, attacks of violent 
mania may set in, and when the storm is over he is no 
longer capable of rational judgment on any point. The 
dementia is now complete. The patient is no longer 
cognisant of his disorder, but lives in an unreal world 
dominated by his exalted or otherwise affected emotions. 
These patients are kings, queens, or whatever their prior 
environment and education has taught their imagination 
to fancy. More rarely there are attacks of depression 
with terrifying delusions. 

The muscular weakness, tremors, and inco -ordination 
become more pronounced. The simplest movements, such 
as tying knots or buttoning clothes, are now clumsily 
executed, and walking and eating are attended with con- 
siderable difficult}'. Even deglutition may become 
difficult. Convulsions and apoplectic attacks occur. Ex- 
haustion and emaciation increase, and death is the end. 



PREMATURE MENTAL WEAKNESS {DEMENTIA PRECOX) 
We have now to consider patients in whom the early 
years of life may present nothing abnormal, some in- 



264 THE VARIETIES OF INSANITY 

dividuals indeed showing promise of quite exceptional 
mental ability, yet who, as they approach adolescence, 
manifest intellectual arrest, with insane and sometimes 
alarming conduct, followed by permanent mental arrest. 
This disease is undoubtedly developmental, and essentially 
the outcome of a neuropathic constitution. It occurs 
usually between the ages of 16 and 22 years. It is 
more common in the male sex than in the female. 

Persons who develop dementia praecox as a rule have 
defective heredity, and manifest a tendency to keep by 
themselves, or to be over-religious, or to indulge in 
day-dreaming and immature philosophising. A lack of 
appreciation and a general inefficiency seem to char- 
acterise their course in life. It affects the better edu- 
cated and highly strung at the period of adolescence. 
Amongst the poorer and agricultural classes it is com- 
paratively rare. It is a disease of civilisation in which 
the original nerve vitality of the individual is limited 
and the powers of resistance prove unequal to the strain 
to which the brain is subjected before development is 
fully completed. 

In the milder cases the symptoms are so imperceptible 
and so little troublesome that they are rarely submitted 
for medical advice, but are looked upon by their friends 
as evidencing unfortunate defects in character and 
conduct. The first chief sign in such cases is an inability 
to perform the usual work or mental tasks with the same 
correctness or facility as formerly. There is a lack of 
application and a general inefficiency. Although there 
may be no apparent lack of endeavour or industry, there 
is a defect in attention and concentration, with mental 
powerlessness. All volition is interrupted, remittent, 
or spasmodic; yet their comprehension is preserved. 

Another characteristic of dementia praecox is an un- 
impaired memory. The memory of past events, espe- 
cially of school knowledge, may be surprisingly good, 
even when the patient is very much deteriorated. Of 
course, when such patients have not used their know- 
ledge for many years, they forget part of it, but not more, 
or even less, than does a sane person who has not exer- 
cised his mind on given things for a long time. But 
while there is the recollection of knowledge previously 



STATES OF MENTAL ENFEEBLEMENT 265 

acquired, there is a curious weakness of judgment and 
loss of interest. The patients are silly, often constrained 
and affected in manner ; such mannerisms are not met 
with as constant accompaniments in any other mental 
affection. They express many absurd ideas, chiefly of 
a sexual and a religious nature. Their beliefs are likely 
to be mystical ; they are inclined to attribute their 
morbid sensations and experiences to the influences of 
others who affect them in some occult way. The most 
improbable beliefs are held unquestioningly. There is 
also from time to time a tendency to fits of depression 
and despondency, or to uncontrollable excitement, or 
to argumentativeness or irritability. There may be de- 
lusions of persecution, even very pronounced; the patients 
may speak of them, but they do not get excited as does 
the paranoiac (Chapter XXI). In dementia prsecox the 
mental weakness is the characteristic symptom, and 
the delusions, if any, are secondary only ; whereas in 
paranoia the delusions of suspicion and persecution are 
the chief symptoms and the mental vigour is retained, 
so that the person can follow his occupation until his 
conduct draws attention to his state of mind. In 
dementia prsecox the patients may seem unconscious of 
their whereabouts or of the identity of their associates. 
They may speak only in monosyllables or in a con- 
tinuous repetition of certain words or phrases, or 
make irrelevant replies or persistently refuse to speak 
for weeks and months at a time, giving the im- 
pression that they do not appreciate what is happening. 
Yet when this phase of the disease gives place to 
another, they may tell accurately much that hap- 
pened during the period when they appeared oblivious 
to everything. Self-absorbed, unconcerned, apparently 
feeling neither joy nor sorrow, they often stare for hours 
into vacancy, wholly occupied with the hallucinations 
that are so prominent an accompaniment of this disease. 

Silly laughter without any appreciable cause is fre- 
quently seen. Periods of unprovoked anger are common. 
They fly at the other patients, break furniture, destroy 
clothing, and so on, without any purpose. These persons 
are apathetic in the performance of their accustomed 
tasks, indifferent to the sorrows of their friends, and 



266 THE VARIETIES OF INSANITY 

often either irritably obstinate and resistive or utterly 
unresponsive to all efforts made to awaken their interest 
in things about them. Others may obey simple direc- 
tions or requests, and many can be trained to do useful 
work in a routine way. 

The main underlying mental symptom is a progressive 
mental weakness and confusion which tends to terminate 
in dementia. During the course of these events the 
patient's memory remains fairly good ; he is quite con- 
scious of his surroundings, and is able on the whole to 
converse rationally and intelligently ; but his conver- 
sations are apt to deviate into foolish bombast or extra- 
vagance. 

The patients appear to be aware of their mental dis- 
turbance and incapacity, but no regret, no care or fear 
for the future, for a moment dims their serenity. They 
become indifferent, stupid, foolish, and improvident, and 
the will-power is affected either in the direction of a 
foolish obstinacy or a no less foolish facility. 

The course of this affection may be arrested at any 
stage after a few months or years ; but it always leaves 
behind it a permanent degree of mental incapacity, 
which lasts during the remainder of the patient's life. 
The mental powers are so enfeebled that most of these 
patients are totally incapacitated from ever again doing 
useful work, in spite of the fact that their memory 
and perception are almost unimpaired. Even in those 
cases which apparently do recover, careful examination 
will usually reveal some degree of mental enfeeblement 
which was not previously present. Many blasted careers, 
blighted prospects, and inexplicable life failures result 
from this disease. Large numbers of beggars and 
tramps, drunkards, prostitutes, and criminals in one 
stratum of society, and of eccentrics and borderland cases 
in other social strata, are the victims of dementia praecox. 

PRIMARY DEMENTIA 

By dementia is meant a permanent state of mental 
enfeeblement — that final wreckage of mind which per- 
mits no opportunity of salvage. By primary dementia 
is understood a form of mental derangement characterised 



STATES OF MENTAL ENFEEBLEMENT 267 

by a more or less complete weakness of the faculties of 
the mind, not secondary to any other form of insanity, 
but beginning as such in an individual previously sane. 
It is to be distinguished from secondary or terminal 
dementia — that variety of mental derangement in which 
there is a decay of the faculties of the mind as a conse- 
quence of some pre-existing form of insanity. Secondary 
dementia is the common goal of the great majority of the 
chronic insane in our asylums. Originating as it does 
from the partial conversion of another species of mental 
aberration, it retains more or less sharply the character- 
istics of the disease from which it has been derived. 
Hence tendencies to excitement, tendencies to depression 
or confusion, illusions or hallucinations, may be present. 
Primary dementia is a rare form of mental enfeeble- 
ment. In its acute variety there is a suspension of all 
the intellectual, moral, and instinctive faculties — in fact 
a mental stupor, without either depression or delusion. 
Ordinarily, the blunting of the mental powers is a gradual 
process, the patient evincing less concern than formerly 
in passing events or in those things in which he would 
naturally be supposed to be interested, such as his family, 
his business, his food, his dress, etc. The higher mental 
faculties, those which are added latest in the scale of 
civilisation as the result of refinement and education, are 
the first to deteriorate. Soon all the intellectual powers 
are degraded. Attention is enfeebled, memory is im- 
paired or even destroyed, and in consequence judgment 
is incompetent and the controlling power over the emo- 
tions is weakened. Dates, places, words, events, are 
forgotten. Even in the simplest matters he cannot arrive 
at a determination. Indeed, he does not make the 
attempt. If left entirely to himself, he would, in the 
extreme stage of the disease, do nothing whatever. If 
asked to rise, walk, or sit down, he acts as a matter of 
course in accordance with the directions given him, pro- 
vided they are commands which are to be obeyed at 
once. Otherwise such commands are forgotten almost 
as soon as they are given. Once the disease is well 
established, the patients become incoherent. Some- 
times they tend to repeat one act or phrase almost in- 
definitely. Sometimes they display excessive joy or 



268 THE VARIETIES OF INSANITY 

grief at the occurrence of what, to persons of normal 
mind, would be slight disturbing causes. Tears are 
therefore shed over the veriest trifles, and violent laughter 
will be indulged in at circumstances which have little, 
if any, of the element of mirth about them. At times 
the individual laughs when he would naturally cry or 
at least feel sorrowful, and sheds profuse tears at some 
circumstance calculated to excite risibility in others. 
Mental ruin and often moral degradation are very marked. 
Such patients neglect all the proprieties and decencies of 
life. The expression is vacant, With fleeting traces of 
emotion, easily aroused and quickly disappearing. There 
are defective nutrition, a lean body often with a voracious 
appetite, and frequently a persistent attitude or habit 
of posture. 

Primary dementia is characterised by a stuporous con- 
dition without any feeling, and must be distinguished from 
the melancholic stupor, which develops out of ordinary 
melancholia (Chapter XIX), and in which there is a painful 
state of feeling. In the first there is the demented, stupid 
expression ; in the other an apprehensive, strained ex- 
pression. In primary dementia there is a relaxed attitude 
and no resistance ; in melancholia with stupor, on the 
other hand, there is a peculiar state of tension of the 
muscles, which is greatly increased by efforts to make 
passive movements. In the former case consciousness is 
absent with forgetfulness for the period of disease, while, 
in the other, consciousness is occupied only by painful 
ideas, and there is quite perfect memory of the events 
of the disease. In the first case, again, there may be 
inability spontaneously to take food from want of under- 
standing, while in the other there is positive refusal of food 
on account of delusions and feelings of repugnance. In 
the first case sleep is usually good, while in the other 
there is sleeplessness. Lastly, there is uncleanliness in 
primary dementia and as a rule cleanliness in melan- 
cholia. 



SENILE INSANITY 

A certain degree of decay of the mental powers is a 
natural consequence of advanced age. It may therefore. 



STATES OF MENTAL ENFEEBLEMENT 269 

within certain limits, be considered a normal change. 
With the majority this amounts only to the loss of a 
certain power of mental assimilation for the events of 
to-day, with a constant reversion to those of youth and 
early middle life, which stand out in very clear perspec- 
tive. To these infirmities are added a certain degree of 
forgetfulness and a loss of the power of logical construc- 
tiveness. 

There are some who lose in virtue, and there are others 
who only lose some faults. Both conditions are due to 
a process of simplification of character. Some become 
petty, headstrong, selfish, and tyrannous over persons 
whom they unfortunately have under control ; they 
lose all feelings of affection, take a dislike to their 
own children, and deny them what they require. With 
the greatest tenacity they cling to their wealth and 
maintain their authority. They become selfish, and 
cease to take an interest in anything save what 
happens within their immediate surroundings. Others 
become over-indulgent over-generous, and childish 
in their simplicity. They have lost some of the baser 
passions. To this change of character may be added 
intellectual enfeeblement, particularly forgetfulness. 

On the other hand examples are constantly met with 
in which the mental faculties are maintained intact to 
a very late age. Therefore old age of itself does not 
cause the mental infirmities with which it is so frequently 
associated. The subject of senile insanity must first of 
all be hereditarily predisposed to the psychosis or have 
arterial disease, or he must be the subject of syphilis, 
alcoholism — either acquired or hereditary — or some other 
conditions which act directly or indirectly upon the 
nervous system. 

The first symptom of approaching dementia is almost 
always such a degree of loss of memory as to cause con- 
fusion about time and surroundings. There is a want 
of understanding of the general situation, a vacuous 
cheerfulness, delusions associated with a certain sense 
of illness, and, above all, a profound failure of attention 
to present impressions. Often there is a complete 
change of character and a lack of carefulness and tidiness 
in regard to personal appearance and habits, with finally 



270 THE VARIETIES OF INSANITY 

a complete disregard of propriety and decency, the same 
as in other forms of advanced dementia. 

Throughout this evolution of a senile dementia the 
individual's own personality is always uppermost ; his 
eating, drinking, difficulties of digestion, the daily altera- 
tions in his corporeal perceptions, good or bad, are always 
uppermost in his contracting mind, and the perpetual 
brooding over trivialities induces mild hypochondriacal 
and melancholic states. Events that do not directly 
concern himself, in his eyes, are of no consequence. 

In his temperament he often shows a curious compound 
of silly mirth and tearful depression, mingled with in- 
creasing complaints of the lack of attention received from 
those who should care for him in his old age. 

Another common and characteristic symptom is the 
excitement or perversion of the sexual impulse, as a result 
of which grey-haired old men may make indecent assaults 
on children or suddenly fall in love with young girls. If 
they die soon afterwards their " vices " are held to be 
the cause, while really the whole history, and their death, 
was the result of senile brain changes. 

Melancholic depression is by far the most common form 
of acute mental disturbance in old age. Delusions of 
personal unworthiness may occur, or that the patient has 
lost his property and destitution is approaching him. 
In other cases delusions of a religious nature predominate. 
Suicide in this state is more common than at any other 
single period of life. Melancholic indications in the aged 
are of serious moment, as they ordinarily mark the be- 
ginning of the period of active decay, ending in a more or 
less permanent dementia. 

Mania in old age is far less common than melancholia, 
and is rarely severe. There is incessant motor excite- 
ment, the patient making continuous, aimless move- 
ments. Incessant garrulity is another symptom, and 
hallucinations may occur. Erotic tendencies and re- 
volting language are common. The tendency after 
prolonged excitement is towards dementia. 

Of the various delusions that afflict the senile insane, 
those of persecution are the most usual, and are an 
outcome of a certain well-recognised mistrust and sus- 
picion. The enemies and persecutors may be members 



STATES OF MENTAL ENFEEBLEMENT 271 

of the patient's own family. Cases have occurred where 
such delusions have led to disinheritance of children, and 
the apparent mental soundness on other points has 
defeated all attempts to upset the will and remedy the 
injustice. There is scarcely any foolish act that may 
not be committed by those suffering from some of the 
forms of incipient senile dementia. Patients of this kind 
often become the victims of designing women, and make 
silly marriages, to their own and others' disadvantage. 
The chief characteristic features are a weakened judg- 
ment, a lack of control of impulses, a childish caprice, 
and often a marked ethical insensibility. 



TESTAMENTARY CAPACITY 

A few observations as to the mental capacity of a person 
at the time of making his will may be appropriate here. 

The physician will have to see whether the patient 
fully understands what is put before him, and can ex- 
press assent or dissent with certainty, whether by articu- 
late, written, or gesture language. 

A man may make a valid will, if he understands the 
nature of the act and its effects. He must know that 
he is agreeing to the disposition of his property after death. 
He must possess, at the time of executing his will, a 
memory sufficiently active to recall the nature and extent 
of his property and the persons who have claims upon 
his bounty, and a judgment and will sufficiently free from 
the influence of morbid ideas or external control to de- 
termine the relative strength of those claims. 

A person may think correctly and sensibly, and may 
yet readily yield to inducements strongly presented to his 
feelings, giving way to outside influences. Sound-minded 
people may and often do ask advice in the final dis- 
position of their property, and the result is very likely 
all the better for it. Such advice may be needed the 
more when the mind is weakened by nature or disease ; 
but when thus obtained, it is viewed by the law with 
suspicion, and the dominant question is, whether or not 
the testator has been subjected to undue influence, 
because sound or unsound, strong or weak, his will must 
be his own will, and not another's. 



272 THE VARIETIES OF INSANITY 

Defect of memory is a very serious bar to will-making, 
but if the person recognises his loss of memory, and acts 
in a way consistent with his past expressed intentions, the 
will may be upheld. If the testator does not recollect 
the number of his children, or whether they are living or 
dead, he may easily make a revocable will ; or there may 
be some loss of memory leaving in him a false impression of 
the conduct of some person. In cases following shock or 
injury, a partial defect of memory may interfere with due 
capacity ; thus I have seen a man who, after concussion 
of the brain consequent upon a railway accident, had 
forgotten that he was married and would not acknow- 
ledge his wife. 

Delusions are looked upon as very strong points against 
testamentary capacity ; but, unless the delusions have 
some direct bearing on the property, or on the relations 
of the testator to his friends, or to society, a jury will not 
pay much attention to them. 

Besides loss of memory and the presence of delusions, 
we have to consider the various forms of weak-mindedness 
which are a bar to testamentary capacity, not only 
because of the mental deficiency of the testator, but 
because such feeble-minded persons are particularly 
subject to undue influence. The mental weakness may 
be due to previous attacks of insanity, or, in previously 
sane people, to apoplectic seizures, which generally leave 
some mental defect, besides depriving the patient in some 
cases of the capacity of speech. 

As regards insanity, no one expects, of course, a person 
in the acute stage of mania to make a will ; he would 
have no desire, nor would he be competent to make one. 
The only question that can arise is as to the competency 
of a patient during a lucid interval of a few hours or days 
when the mind is restored more or less to its normal 
clearness. To the common eye, any remission in which 
the patient is tolerably calm after being violent, and 
answers a few questions rationally, seems like a lucid 
interval, but that the mind is absolutely sound and 
working normally during such remission no expert would 
assert. We do not refer, of course, to the really lucid 
intervals of periodic insanity (Chapter XX), and the in- 
terval between relapses after apparent recoveries. 



CHAPTER XXIII 
MENTAL DISORDERS DUE TO INTOXICATION 

ALCOHOL, OPIUM, AND COCAINE POISONING 

There are certain forms of mental disorder due to the 
toxic effects of alcohol or drugs. The manifestations 
depend upon the quality and character of the poison 
taken, upon the susceptibility of the one taking it, and 
upon the length of time the patient has indulged in the 
use of the poison. 

ALCOHOLIC INSANITY 

In quite small quantities alcohol acts first of all as a 
stimulant, puts the person in an agreeable frame of 
mind, fires his imagination, and gives vivacity to his 
conversation. That is why it is given at dinner parties. 
It puts the guests in good humour, in a happy frame of 
mind, and makes them more attractive to one another. 
The stimulant effect does not last however, it is only 
immediate. Alcohol soon ceases to have a stimulating 
effect and acts as a sedative, giving repose to the body 
and a quietness to the mind and conscience. It is to 
produce these latter results that it is taken by people 
in misery or trouble, not as a stimulant, for then it would 
increase their sadness, but rather as a sedative to their 
feelings. Those persons who have not had a happy life 
find a glass of wine a pleasant companion ; it causes 
diminution of sensibility, drowns their trouble and 
grief, and, if it does not give complete felicity and forget- 
fulness, it dulls thought and obscures the painful feelings. 
They know that they may feel a little stupid, but they 
also know that all things they may view will appear in 
a rosier light. The man drinks because it makes him 
18 273 



274 THE VARIETIES OF INSANITY 

cheerful, modifies the course and colours of his ideas, 
and gives him forgetfulness or sleep. 

When taken in larger quantities, alcohol lowers all the 
functions of the body, producing loss of sensibility and 
of motor power, and may produce temporary paralysis. 
The anaesthetic effects of alcohol are well known, as for 
instance in the case of a drunken man in a quarrel, who 
is quite insensible to the blows or other injuries he is 
receiving. 

When alcohol is imbibed freely, we have first of all 
slight excitement and a feeling of well-being, in which 
speech and gestures become more animated, resembling 
very much the state of hypomania (Chapter XVIII). 
There is at first a paralysis of the inhibitory apparatus, 
the loquacious stage, when the person becomes talkative, 
gay, and lively ; he thinks he is very funny and even 
witty, when perhaps he is uttering the most common- 
place remarks or reiterating the most absurd statements. 
The general expression becomes one of silly self-satis- 
faction, with a fatuous smile, which may be blended with 
a look of astonishment. The ideas become crowded 
together and confused. The curb which fear of public 
opinion puts on the free expression of emotions and 
ideas and the veil which hides the real moral disposi- 
tions are removed, Whence the justification for the saying 
in vino Veritas. There is interference with the processes 
of thought, ideas succeed each other so rapidly that 
there is no time to arrange them in orderly sequence. 
The emotions get unstable, the mood becomes, without 
any very obvious reason for the difference, gay or sad 
or full of tenderness. Whether the excitability will 
tend towards joy, melancholy, or anger depends on the 
environment. The person laughs sometimes at the 
least little thing ; weeps or grows sentimental or maud- 
lin ; gets angry at the slightest cause. He may be 
argumentative and even pugnacious ; he becomes pro- 
fane, obscene, abusive, threatening, and may be violent. 
The exaggerated feeling of strength and well-being soon 
passes ; his movements are poorly controlled ; his gait 
becomes staggering and his speech thick. 

So long as the person is seated he may speak and discuss 
subjects quite distinctly and rationally, and yet, when 



DISORDERS DUE TO INTOXICATION 275 

he attempts to walk, he may not be able to take one 
step, in fact, may not be able to stand. On the other 
hand he may be able to walk quite steadily, yet be unable 
to articulate one word. 

This particular stage of drunkenness often leads to 
considerable difficulty in police-court cases, for the 
person in this condition has lost control of the muscles 
of locomotion, but has control of the muscles in con- 
nection with speech, and, having steadied himself against 
the counter, he can speak coherently and quite distinctly. 
The policeman, having seen the staggering gait, swears 
that the man was drunk ; the bar-attendant, having 
heard the clear speech, swears the man was sober, other- 
wise he would not have supplied him. 

-A little later the conduct becomes more and more 
reckless; his smile, a besotted grin; his intellect more 
and more dulled ; a temporary paralysis may supervene, 
the person becoming insensible and unconscious. After 
sleep he wakens with headache, weakness, nausea, and 
loss of appetite. 

It is related in an old rabbinical legend that after 
Noah had planted the vine that God had given him, Satan 
secretly watered it with the blood of a lamb, of a lion, 
and of a pig. The order in which these animals are 
named, though very likely without intentional signi- 
ficance, is interesting, for it corresponds roughly to the 
successive stages of acute vinous intoxication ! First, 
the stage of mildly soporific euphoria ; secondly, that of 
noisy, garrulous, and actively quarrelsome excitement ; 
and lastly, that of bestial and abandoned lethargy. It 
is during the second stage that a very large proportion 
of all crimes of violence are committed, and the sudden 
and often explosive appearance of this phase is not at 
first sight apparent. 

ACUTE ALCOHOLISM {DELIRIUM TREMENS) 

Acute alcoholism generally follows excessive drinking 
in otherwise normal persons. What may be excess to 
one person need not be so to the other. Persons suffering 
from shock, distress, physical disease, accidents, or any 
brain effect, temporary or permanent, and lastly, persons 



276 THE VARIETIES OF INSANITY 

not accustomed to alcohol, may feel the effects of its 
intoxication after very small quantities, which would 
have no effect at all on the habitual drinker. Acute 
alcoholism generally develops suddenly. The chief mental 
characteristics of acute alcoholism are terror, mental 
distress, and confusion of ideas. Chief amongst the 
physical signs is a fine muscular tremor, most marked 
when the attention is distracted. If the movement is 
made rapidly, the alcoholic may carry a glass to the 
mouth without spilling the contents ; but if the attempt 
is made slowly, the feat will be difficult of accomplishment. 

The prominent symptom of acute alcoholism is the 
affection of the special senses, especially those of sight 
and hearing. Visual hallucinations are the most fre- 
quent, those of aural origin being second in importance, 
while a combination of the two is of common occurrence. 
Hallucinations of sight in this affection have the pecu- 
liarity that they generally appear in motion. The 
patient sees animals of the most repugnant description — 
cats, dogs, snakes, and spiders ; and creeping things of 
every description are seen to emerge from the walls or 
floors or to creep along the ceiling, and not infrequently 
assume a threatening attitude. They are the cause of 
inexpressible terror, and form one of the most distressing 
symptoms of the affection. Hallucinations of sight are, 
however, not limited to those described, but may in- 
clude apparitions of spectres, phantoms, assassins 
seeking for the patient's life, flames of fire, demoniacal 
forms, and strings, threads, and ropes which entangle 
the body are often felt. 

Even more characteristic of alcoholic delirium are the 
delusions arising from perversions in the nervous func- 
tioning and manifesting themselves as burning sensa- 
tions, formication, tingling, anaesthesia, or numbness over 
different portions of the cutaneous surface or electric- 
like shocks. 

The alcoholic conceives these abnormalities of sensa- 
tion as the result of the machinations of diabolical agents, 
of witchcraft, of mesmerism, of hidden electric batteries, 
and accordingly builds upon them a whole host of de- 
lusions, mostly of a persecutory type. He has fallen 
into the snares of inimical persons, who torment him for 



DISORDERS DUE TO INTOXICATION 277 

their own ends, who restrict the free rise of his mind, 
enslave his thoughts, and destroy every joy and pleasure 
of his life. Sometimes he has optimistic fancies, but even 
then they are intermingled with delusions of distrust. 

Hallucinations of hearing are also common. The 
patient complains of ringing in the ears, sounds like the 
rushing of waters, musket shots, whistlings, or voices 
which threaten him with death or accuse him of imaginary 
crimes. 

Hallucinations of smell and taste are more frequent 
in alcoholism than in other forms of insanity. They 
give rise to delusions of suspicion and persecution. The 
patient complains that his food is poisoned or that foul 
substances are mingled with it, that attempts are being 
made by enemies to chloroform him in his bed at night, 
that poisonous gases are injected into his room through 
the keyhole, and that foul odours pervade his apartments. 
Goaded by these persecutions, the pursued may turn upon 
his supposed enemies and attempt to kill or injure them. 

The bearing of all acute alcoholics shows restlessness 
and anxiety. They cannot control their movements or 
keep quiet for more than a few moments at a time. 
They wander about their apartments, making violent 
attempts of an impulsive kind to escape from their imagi- 
nary dangers. Some of them rush unconcernedly 
straight in front of them, breaking or overturning any 
object which opposes itself to their flight. 

Even during the height of the excitement the patients 
are conscious of the surroundings, although they require 
to be spoken to loudly and firmly in order to arrest 
their attention. Yet their recall to active conscious- 
ness is generally temporary, and they speedily return 
to the engrossing subject of their hallucinations. The 
memory of the patient usually remains intact, so that 
he is able to retail after recovery what had occurred 
during the period of greatest confusion in his illness, as 
well as the symptoms by which it was characterised. 

CHRONIC ALCOHOLIC INSANITY 

The continued excessive use of alcohol has its effects 
on the mental health in other ways than in producing 



278 THE VARIETIES OF INSANITY 

acute delirium tremens or alcoholic mania. Chronic 
alcoholism shows itself in gradual and progressive mental 
deterioration and in certain physical changes that show 
the deplorable effects of the poison on the central nervous 
system and on the bodily organs and functions. 

The mental enfeeblement is slow, but progressive. At 
first the person feels unable to apply himself to the 
tasks he formerly did with ease, his mind wanders, he 
has a growing sense of fatigue ; later he shows impair- 
ment of judgment, poverty of ideas, and gradual failure 
of memory. While forgetfulness is characteristic of all 
forms of chronic alcoholism, the loss of memory may be 
so prominent as to constitute a special form of the disease. 

The characteristic sign of this type of the malady 
is the instantaneous forgetfulness of events that have 
only just transpired. Thus names, or the simplest sen- 
tences, repeated over and over again to the patient, are 
totally forgotten either instantly or after the lapse of a 
few moments, nor does there exist any possibility of 
their recall in the future. 

There is marked enfeeblement of the will, so that 
there is not the power, and often not the desire, to rise 
out of the rut of habit. This enfeeblement of the will- 
power is not confined to the inability of the patient to 
resist his alcoholic craving, but extends to other matters 
as well, so that he loses his power of initiative and of 
asserting himself, and becomes incapable of performing 
any work, except according to routine, and so becomes 
the tool of other people, by whom he is influenced and 
easily diverted from his purpose. 

The person gradually undergoes a change in char- 
acter : he becomes untruthful, loses his finer sense of 
honour ; he, little by little, grows lax about things con- 
cerning which he was formerly most particular. He 
becomes indifferent to his own interests, and regardless 
of the feelings or prosperity of his family and friends. 
He sees those depending upon him suffering want and 
shame, yet pursues his downward course, seemingly in- 
different to their needs or their entreaties. Sometimes 
he falls so low that he will pawn the clothing his wife 
has earned in order that he may procure money to buy 
another drink. 



DISORDERS DUE TO INTOXICATION 279 

Another striking feature is an unreasonable irritability, 
which frequently leads to outbreaks of passion of a 
blindly impulsive character, of which his family or his 
associates are often the victims. Wife-beating, inhuman 
treatment of children, attacks upon associates on the 
slightest provocation, are of daily occurrence during the 
stage of inebriety. 

Along with the above symptoms, muscular weakness 
is apparent ; a fine tremor may come to be a pretty con- 
stant symptom, but coarser muscular twitchings also 
occur. Frequent headaches, dizziness, difficulties in 
speech and gait, are common, and convulsive seizures of 
an epileptoid character may appear. In the pronounced 
forms of chronic alcoholism we find a more decided blunting 
of common sensations. 

The most diagnostic sign, however, is a painful condition 
of the nerves of the limbs — namely, neuritis. 

Any form of insanity may occur in the course of chronic 
alcoholism, but the character of the insanity is always 
more or less modified by the chronic mental condition, 
which may be mania or melancholia, according to the 
predisposition of the patient. 

The most characteristic and most commonly occurring 
form of insanity is mania of persecution, produced by 
hallucinations. Hallucinations of sight are always present 
in the alcoholic form. The patients are perfectly con- 
scious, and suffer horribly in this disease. The prevailing 
delusions refer to the sexual relations and to poisoning. 
These delusions are so constant that, when a patient 
complains of attempts being made to mutilate him 
sexually, of the unfaithfulness of his wife, and of his food 
being poisoned, we are almost safe in assuming that 
alcoholism is the cause of his symptoms. 

The effects of steady, hard drinking are, however, 
not always the same. Some appear to escape the con- 
dition described ; they retain their judgment and energy, 
and appear like good citizens and capable business men. 

Many individuals undergo this complete change of 
character without openly appearing under the influence 
of liquor, and it may occur from a habit of secret drinking 
alone, which in some respects, and in some persons, is 
even more dangerous than the open habit. They cannot 



280 THE VARIETIES OF INSANITY 

be regarded as altogether escaping the effects of their 
habit, and sometimes a peculiarly characteristic form of 
alcoholic insanity may develop. They suffer only from 
a certain degree of irritability and suspiciousness, which 
they may be able to control in public, but with their 
families it is manifest. They misinterpret the simplest 
facts and build up complete delusions. One of the most 
frequent of these is that of conjugal infidelity, which is 
only the simple result of irritable jealousy, interpreting 
the natural disgust or precautions for self-protection on 
the part of the wife as the evidences of her unfaithfulness, 
and this, with the ill-balanced state from alcoholism, 
develops into a fixed delusion. This morbid suspicious- 
ness, aggravated by intellectual weakness, builds up 
sometimes, from very trivial circumstances, new evidence 
in support of the delusion. Many a wife will face re- 
peated danger to herself from a husband so insanely 
jealous, and only ask for protection if his threats or acts 
make her fear for her children's safety. 

These delusions of marital infidelity, so common in 
the course of the disease, when once formed, are nearly 
always permanent, and are naturally the source of 
bitter strife and constant dissensions between man and 
wife. 

The hallucinations and delusions foster irritability 
and roughness of manner and action ; the individual is 
ready to take offence even without provocation, believing 
that family and friends are hostile to him. 

The outbreak of alcoholic mania is sudden, often 
coming on as the result of an overpowering sense -decep- 
tion of mortal fear or of imminent danger. While in this 
state the individual is highly dangerous to those who 
chance to be in his immediate neighbourhood, and 
numerous unmotived murders have been committed by 
such persons, who, on recovering, have not the slightest 
recollection of any event that has occurred during this 
period of excitement. The chronic alcoholic is a constant 
menace to his family and to society at large. Most 
chronic alcoholics, if they live long enough, end in de- 
mentia. As a rule the mental and physical conditions 
progressively deteriorate, until the patient becomes 
physically powerless and mentally extinct. 



DISORDERS DUE TO INTOXICATION 281 

CHRONIC OPIUM INTOXICATION 

Second only in importance to alcohol, among the 
chemical poisons that produce a chronic intoxication 
showing psychical features, stands opium with its deriva- 
tive morphine. 

To some extent the notorious intolerance of the 
present generation to pain is largely responsible for the 
increase in drugging habits, a toothache or a neuralgia 
being sufficient cause or excuse for the sufferer to fly to 
morphine or some other narcotic for relief. 

The first effect of morphine is to make one think 
quickly and clearly, but this soon passes away and a 
dreamy state supervenes. About half an hour after the 
drug has been swallowed, or inhaled, as in the Oriental 
opium smoker, the subject experiences a feeling of well- 
being, which is followed by one of pleasant drowsiness. 
Just before the drowsiness sets in the subject feels that 
he could be master of any situation, but he enjoys the 
sensation of rest too well to take part in activity. The 
limbs become placid before the intelligence shows signs of 
inactivity. Little by little the mentality also becomes 
effaced and is accompanied by incorrectness of percep- 
tion ; adjacent sounds appear as if they were struck at a 
marked distance ; the surroundings become more and 
more indistinct, until they seem as if enveloped in a mist, 
the individual becoming conscious of a great silence around 
him, in which he feels as if his body were almost imma- 
terial. Ideation also changes ; every problem seems easy 
of execution, and life is seen in its rosiest colours. All 
that surrounds the subject bespeaks a serene display far 
above the vulgar scenes of everyday life ; precious 
metals, soft and valuable materials, and things in unison 
with royal purple surround him, and harmony of senti- 
ment binds him to those about him. These expansive 
ideas are not only characteristic of the intellectual, 
but they are met with in the unintellectual as well. 
The period of pleasurable excitation is followed by one 
of somnolence. The subject is then in a perfect con- 
dition of beatitude — nothing annoys him, everything 
seems harmonious to him ; he makes no attempt at 
action, satisfied with what seems to him to be existing 



282 THE VARIETIES OF INSANITY 

around him. In some cases these pleasurable effects are 
not experienced, and in their stead headache, nausea, 
colic, and other uncomfortable symptoms are felt. 

A temporary insanity may occur in habitues after an 
unusually large dose ; the symptoms are temporary, and 
consist of hallucinations of sight, mental distress, or an 
apathetic somnolence, with mild delirium, from which the 
person is with difficulty aroused ; and also during the 
period of treatment, when the drug is suddenly stopped, 
or too rapidly discontinued, and insanity similar to 
delirium tremens, with hallucinations, maniacal agitation, 
and confusion of ideas may supervene. This state is at- 
tended with tremors and uneasiness, peculiar sensations 
in different parts of the body, obstinate sleeplessness, 
with great physical prostration, twitchings, palpitations 
restlessness, cramps and pains throughout the body, 
which continue for several days after the mental 
symptoms have disappeared. Chronic morphia intoxi- 
cation produces a mental condition in many respects 
similar to chronic alcohol poisoning. But the intoxica- 
tion is not, like that of alcohol, a motor one ; as a rule 
the subjects are quieter, not uproarious or dangerous. 

Persons who continue the use of morphine fail to get 
the acute effects, but they are held in its power because 
of its ability to exhilarate them temporarily, enough to 
make them forget their troubles. They find to their 
dismay, however, that in order to get this result they 
must increase the quantity of the drug and repeat it 
oftener. No physician should ever place a hypodermic 
syringe or a prescription for morphia, renewable at will, 
in the hands of his patient with instructions how to use 
it. The permanent effect upon the faculties in those 
instances in which the abuse of the drug has been long 
continued, or the amount taken excessive, is shown in 
impairment of memory and lessened ability to apply 
one's self to physical or mental work. The stability of 
the emotions is conspicuously affected. Persons in- 
dulging in morphine are easily dejected and irritated. 
Anxiety, especially at night, is often experienced. 

The moral nature undergoes grave changes, as shown 
in pronounced moral obliquities, and in the resort to any 
means, no matter how unscrupulous, even actual forgery 



DISORDERS DUE TO INTOXICATION 283 

and theft, to obtain the drug. The idea of any personal 
responsibility falls to the lowest ebb ; thought, action, 
and even the most imperative duties are shunned. While 
the largest numbers of these unfortunates are not insane 
in the stricter sense of the word, there is always present 
a certain degree of ethical obliquity, irritability, peevish- 
ness, and moroseness. They lie unblushingly. It is 
never safe to believe the word of an opium-eater— he 
will prevaricate with or without reason ; his disposition 
is uncertain and treacherous ; his conscience is obtunded ; 
he is dissolute i and has tendencies to morbid impulse. 

These patients often complain of numbness or hyper- 
sensitiveness ; their pupils are usually contracted, their 
gaze furtive or staring ; they are usually pale, with 
marked pallor of lips or ears. Some of them get hypo- 
chondriacal ; others become weak and tremulous, lose 
flesh, suffer from dizziness, fainting spells, profuse per- 
spiration, and palpitation. 

If insanity does occur, it is characterised by delusions 
of persecution or by delusions of grandeur. These 
mental symptoms only occur, as a rule, after prolonged 
indulgence or in those highly predisposed to the psy- 
choses, or where both factors are combined, and are 
usually accompanied by a varying degree of mental 
weakness. 

COCAINISM 

Cocainism is the condition of physical and mental 
enfeeblement due to the extended use of cocaine. There 
is hardly any drug that so quickly drives away care and 
produces a feeling of well-being and satisfaction, or that 
more insidiously leads to excessive indulgence, and 
finally to mental derangement, as cocaine. 

Cocaine mildly exhilarates at first, much as does 
alcohol ; the patient becomes lively and talkative, and 
feels like undertaking schemes, feels increased mental and 
muscular power, but soon grows drowsy and inactive. 
Some persons are so susceptible to the drug that even 
small doses are followed by delirium and collapse. The 
patient grows pale and sickly-looking, loses weight 
rapidly, acts sleepily, has no appetite ; he may have 



284 THE VARIETIES OF INSANITY 

twitchings, tremors, palpitations, fainting spells, and his 
sleep, poor as it is, may be disturbed by hallucinations, 
followed by delusions of a persecutory nature. 

Those who become addicted to the extended use of 
cocaine are in a pretty continuous state of excitement ; but, 
busy as they are, they seem incapable of applying them- 
selves to any effective work. They show a deplorably 
weakened will, a steadily failing memory, and much 
misdirected energy. They are extremely loquacious, are 
given to writing long letters or articles, and are prone 
to advance many impracticable schemes. Elation and 
depression frequently alternate. Suspicion develops, 
affection for friends diminishes, and they grow callous 
to all obligations and ties. 

In chronic cases, hallucinations of the various senses 
may become distressing, especially those of sight and 
hearing. Black specks before the eyes, visions thrown 
on the walls, threatening and insulting voices, a feeling of 
electricity being turned on, or of poison being thrown 
at them, are common experiences. These give rise to 
increased suspicion and suffering, and patients often 
grow to believe themselves the victims of deep-laid plots ; 
they think themselves watched and followed, reviled, 
tortured, and perhaps about to be murdered or otherwise 
foully dealt with. Insane jealousy is another prominent 
symptom. 



CHAPTER XXIV 

MENTAL DISORDERS PECULIAR TO WOMEN 

Women who are predisposed to insanity run special 
risks during their functional activity, especially during 
the periods of pregnancy, parturition, and lactation. 

MENTAL DISTURBANCES IN DISORDERED MEN- 
STRUATION 

The nervous disturbances which accompany menstrua- 
tion in some healthy women are well known. In a few 
cases these disturbances take the form of obsessions or 
impulses. As a general rule, however, mental troubles 
in connection with menstruation are only observed in 
those cases in which the function is profoundly dis- 
ordered, the menses being either suppressed for a long 
period, or occurring at irregular intervals, or accom- 
panied by great pain and constitutional disturbance. 

The restoration of the function is often followed by 
the return of sanity, but the fact must be remembered 
that during insanity the menses are in the great majority 
of cases suspended at the commencement or during the 
course of the malady, so that cause and effect are not 
easily distinguished. 

The mental disturbances are most marked at the 
cessation of the function of menstruation, and will be 
described under ** Climacteric Insanity." 

MENTAL CHANGES IN PREGNANCY 

The nutritional disturbances to which all women are 
subjected during pregnancy allow few of them to escape 
at least some alteration of the disposition, When slight, 

285 



286 THE VARIETIES OF INSANITY 

these changes are manifested principally in the form of 
capriciousness, abnormal appetites and cravings, ten- 
dencies toward brooding over possible ill results of the 
pregnancy to themselves, or some slight degree of mental 
exaltation, in which the imagination is more particularly 
disturbed. 

Insanity of pregnancy is most commonly associated 
with some very distinct neurosis in the individual herself 
as well as in her family. As a rule the symptoms are of 
a more or less melancholic type, with loss of mental 
power, of will, and energy. There may be a special 
dislike and distrust of the husband and aversion to the 
other children. They suspect their husband of in- 
fidelity, fancy that they are going to be abandoned, or 
that their children are to be taken from them. There 
may be complete apathy and loss of interest in family and 
surroundings, weariness of life, delusions of having com- 
mitted unpardonable sins, of being unworthy to live, 
and the thousand-and-one deceptions of the melancholic. 
The melancholia may become more pronounced during 
the later months of pregnancy. 

Occasionally the patients suffer from mania of the 
ordinary type, with restlessness, insomnia, loquacious- 
ness, motor agitation, with or without hallucinations and 
delusions, according to the severity of the attack. The 
mental disorders rarely last during the entire pregnancy, 
and when they do, the patient usually recovers after 
delivery. 

INSANITY FOLLOWING CHILDBIRTH {PUERPERAL INSANITY) 

During the first few weeks after delivery of the child, 
mental disturbances in those predisposed to it, or who 
have already had an attack, are again liable to occur. 
The insanity is due to septic intoxication or resulting 
from the storing up in the system of waste tissue products. 
The symptoms are of the hallucinatory-confusional motor 
and mental types of excitement, delusions, stupor, or 
melancholic indications as in all inanition psychoses. If 
suicide is attempted, it is the direct consequence of 
frightful hallucinations and entirely unpremeditated, 
and not from a sense of unworthiness and premeditated, 



DISORDERS PECULIAR TO WOMEN 287 

as in melancholia. Infanticide during transient attacks 
of this form of insanity is not uncommon. The excite- 
ment is often intense, the patient injuring herself in 
attempts to escape from restraint. There is none of 
the loquaciousness of the true maniac ; on the contrary, 
speech is often reduced to disjointed, unconnected words, 
and, when spoken to, the woman either pays no atten- 
tion or stares at the person addressing her in a blind, 
uncomprehending way. She is absolutely sleepless, re- 
jects food, and is regardless of her person and the 
ordinary decencies. 

INSANITY OF THE LACTATIONAL PERIOD 

This form of insanity begins after the second month 
after parturition. It also belongs to the type of inanition 
insanity, only that the hallucinatory maniacal form is the 
more frequent. 

For weeks, perhaps months, the patient has shown 
sleeplessness, loss of memory, decline of the faculty of 
attention, a progressive pallor, digestive disturbance, 
the evolution of morbid fancies, and a change of dis- 
position toward her infant and the household. If she 
continues to nurse her child, she becomes more and more 
anaemic, and eventually develops hallucinations, aural, 
visual, or mixed, with increasing obtuseness and con- 
fusion of thought. 

Under the influence of terrifying hallucinations she 
may attempt suicide, take the life of her infant, or, under 
a false conception of the identity of those around her, may 
violently assault husband, mother or nurse. Periods 
of quiet may follow, and delusions of a persecutory type, 
such as being poisoned, may occur. Finally a stuporous 
condition is by no means infrequent. 

MENTAL CHANGES OF THE CLIMACTERIUM 

Undoubtedly brain changes may occur at the time of 
change of life, when the sexual function departs. When 
the hereditary and personal history has been good, and 
there has been no special stress, the change takes place 
so gradual as to be imperceptible. All the mental powers 



288 THE VARIETIES OF INSANITY 

are lessened in activity to a certain degree, and the 
woman, and, as a matter of fact, also the man (see the 
author's articles on " The Change of Life in Man — Clima- 
terium virile," in the Neurologisches Centralblatt, December 
i, 1910, and Medical Press, December 28, 1910), have to 
adapt themselves to their reduced energies. 

Life's enjoyment has diminished and fatigue sets in 
more readily. At the same time the defence against 
disease is lowered, and often this is the beginning of the 
end, the time when the first signs of that illness set in 
to which, in after-years, the individual succumbs. For 
both sexes the climacterium is a period for the re -adap- 
tation of the bodily machinery to a more modified func- 
tional activity. If then there are cares and sorrows, 
mental or physical over-exertion, it will be more difficult 
than ever to retain the elasticity. At any other time the 
body would have recovered easily. Now there are not 
enough vitality and nervous energy, or only after a 
period of long inactivity. 

The patient complains principally of a loss of his ac- 
customed energy, sometimes to the extent of drowsiness 
during the day. Men who are intellectual workers com- 
plain that they have no longer the same intuition and 
inspiration, and lack the ability of their former concen- 
tration. The intellectual processes are both retarded and 
more difficult. The imaginative power being diminished, 
it is harder for them to originate new work. In conse- 
quence they become dissatisfied and are addicted to 
grumbling — in short, nothing pleases them. They are 
impatient of opposition. They are easily provoked to 
anger, even by persons whom they love. The accustomed 
pleasure and enjoyments have lost their charm and 
interest. Hence they restlessly pursue changes, or else 
are not moved to go out-of-doors. They become very 
emotional, and are ashamed of it. They cry easily, and 
can with difficulty suppress their tears. Family events, 
the theatre, music, and the sight of misery excite their 
feelings to an unusual extent. Many patients complain, 
in addition, of what is commonly called "stage-fright/' 
The brilliant orator, the distinguished performer, the 
busy speculator, now dread public assemblies, or come 
suddenly to a standstill. Thus memory fails them, they 



DISORDERS PECULIAR TO WOMEN 289 

forget what they intended to say, or play, or reckon. 
After one or more accidents of this nature they are 
overcome by chronic fear, dreading some misfortune, they 
do not know of what kind ; they can only say that they 
feel they will always be helpless or ill. The diminished 
capacity for work makes them fear poverty. In conse- 
quence of the anxieties sleep is disturbed. The patient 
becomes sad and depressed, " love of life ' is di- 
minished, and not infrequently attempts are made at 
self-destruction, which take the family all the more by 
surprise since no real motive can be found for such con- 
duct. 

Like the flickering flame before it extinguishes will often 
burn up high, so the sexual instinct before it is lost will 
show abnormal functioning, and many a woman at this 
" dangerous age " will do "silly" things — fall in love 
with a much younger man who spurns her, and conduct 
herself in a manner that makes her the laughing-stock of 
her friends. Erotic delusions may occur. Elderly men 
will fall in love with girls who have hardly passed infancy, 
and many a family of grown-up sons and daughters have 
been shocked by a widowed father who married a girl 
of the same age or even younger than themselves. 

The revival of the sexual passion may cause the wife 
to believe that she is neglected for some other woman, 
or a feeling of antipathy to the husband may arise which 
becomes interpreted for dislike on his part. In either 
case the woman becomes suspicious and is on the look- 
out for evidence, when trifles, light as air, suffice to 
satisfy her. One woman searches her husband's pockets, 
while another deciphers in a mirror the writing on his 
blotting-pad. When once the false idea has got fairly 
established, reason is of no avail to disturb it. During 
this stage of insane jealousy, acts of violence and destruc- 
tion are common, and frequently libellous letters and 
post-cards are written, thus causing public scandal. 



19 



CHAPTER XXV 

MENTAL AFFECTIONS OF CHILDHOOD 

NIGHT TERRORS, CHOREIC AND EPILEPTIC INSANITY 

Unsoundness of mind, apart from congenital defect and 
delirium, is rarely seen in childhood during the period of 
life from the first to the twelfth or fourteenth year — i.e. 
up to the age of puberty. 

The numerous forms of idiocy which will be described 
in a succeeding chapter do not belong here, since idiots 
are not, properly speaking, subject to insanity. Their 
mental peculiarities are not to be regarded as symptoms 
of alienation, but rather as the result of lack of develop- 
ment of the higher brain centres. 

Fits of prolonged screaming, motor restlessness, and 
sleeplessness may occur even in tiny infants, but since 
they are too young to connect any ideas logically until 
the age of four, any mental disturbance which occurs at 
such an immature age must be of a purely hallucinatory 
nature and cannot include delusions. Such young chil- 
dren have delirium, nocturnal frights, ; and transitory 
maniacal attacks, accompanied by sensorial deceptions. 

In children between the ages of four and seven years 
the hallucinatory types of mental disorders still pre- 
dominate, but are mainly induced by infectious and 
toxic maladies. Delusions, rudimentary in character, 
extravagant and grotesque from the imperfect judg- 
ment and lack of experience, may be occasionally noticed 
in the latter part of this epoch. 

From the end of the seventh year to puberty, modified 
forms of adult insanity begin to come into prominence. 

Insistent ideas and compellent motor acts are by no 
means uncommon in childhood, and are referable to ill- 

290 



MENTAL AFFECTIONS OF CHILDHOOD 291 

health and sometimes overwork. They occur in older 
children approaching puberty, but they are not unknown 
at six and seven years of age. Quite a number of the 
phobias, such as morbid fear of being alone, of the dark, 
of crowds, or of open spaces, develop out of the natural 
timidity of childhood, combined with the effects upon the 
immature nervous organisation of weird tales related to 
them without due consideration of their effect upon un- 
restrained and vivid imaginations. 

Mania as it is known to us in the adult does not exist 
in childhood, but something akin is witnessed when the 
infant is uncontrolled by direct moral suasion, is pro- 
foundly egotistic, destroys for the sense of pleasure 
destruction brings, talks disjointedly, and makes in- 
cessant violent movements. 

Hallucinatory confusional delirium occurs in post- 
febrile and inanition psychoses. The children change in 
character, become restless, and suddenly exhibit intense 
irritability. Then after hours or days hallucinations 
make their appearance. The anxiety is intense, and the 
disturbance produced by the appalling visions induce a 
profound mental confusion, in which the most simple acts 
of reflection are in complete abeyance. The child strikes 
at any one approaching him or seeks to evade them. The 
parent or nurse is unrecognised, and control is only to 
be obtained by force. The duration of the active symp- 
toms is from two to ten days. There may follow a stage 
of depression lasting for weeks, interrupted by exhibitions 
of anxiety and moroseness. 

In chorea (St. Vitus's Dance) there is often a mild mental 
disorder. The character of the child afflicted becomes 
changed ; there are lapses in the moral sense, mendacity, 
perverseness, emotional outbreaks, irritability, and the 
constant repetition of meaningless actions. Distur- 
bances of memory and of the faculty of attention are 
also common. The child apparently forgets what it has 
previously learned ; reading and writing become difficult ; 
there may be maniacal delirium, and the impairment of 
intellect may proceed to a more distinct alienation — a 
transient or permanent dementia. 

Melancholia occurs as a rule only at puberty. The 
child afflicted with it withdraws from the companionship 



292 THE VARIETIES OF INSANITY 

and games of his companions, neglects his lessons, becomes 
introspective, loses his interest in life and his affections, 
and grows gloomy and spiritless. Actual delusions 
are found only in older children. Hallucinations are 
exceedingly rare. Suicidal impulses are often present, 
and should be guarded against with the most pains- 
taking fidelity. Suicide in childhood is always pre- 
meditated, and is sometimes effected in ways that would 
be unthought of by an adult. 



NIGHT-TERRORS 

Night-terrors occur in children between three and 
eight years. They are due to reflex irritation of the brain, 
set up probably by digestive disturbance. The child, 
without apparent reason, will suddenly start up in bed 
and scream continuously for some minutes, and have his 
hands outstretched as if to shield himself. His face 
expresses wildest alarm, his eyes are wide opened, with 
pupils dilated, and he gazes intently at the ceiling or 
towards some quarter of the room in which he locates 
the apparition which frightened him. 

The child will cling instinctively for protection to 
any one within reach, but he does not at first look at or 
recognise persons — his attention is fully taken up by the 
imaginary object of his fear. The period of terror lasts 
from a few moments to half an hour. The child usually 
then recognises his surroundings, but he sweats and 
trembles, turns pale, and seems shocked and exhausted. 
He will beg not to be left alone in the dark again or that 
his hand may be held. 

Although visual hallucinations are commonest in 
young children, other hallucinations, such as those of 
hearing and of common sensation, besides those of sight, 
may occur in night-terrors. A healthy child may be 
merely frightened and will be none the worse the next 
day, whereas the emotional and neurotic child will be 
haunted by the terrors he has experienced. Unusual 
timidity is often an early sign of such tendency. He 
grows up shy and self-conscious, and becomes neuras- 
thenic or hysterical. 

Night-terrors are to be distinguished from nightmares. 



MENTAL AFFECTIONS OF CHILDHOOD 293 

Night-terrors seldom occur in children over eight years of 
age. They may occur only once a night, but they never 
vary. The attacks may occasionally trouble a healthy 
child, but the children most often and seriously affected 
are those who are themselves neurotic or are the progeny 
of neurotic parents. The child may seem wide awake, 
yet still see the vision that has terrified him, remain un- 
conscious of his surroundings, and have no recollection 
of the event afterwards. 

Nightmares may happen at any age. They occur 
generally in chronic ill-health, but there is no family 
history of neurosis as a rule. Several attacks may happen 
in the course of the night . The child has a troubled dream ; 
the objects of apprehension have been met in waking 
hours, and are not invariably the same. When aroused 
from its troubled sleep, the child is perfectly conscious, 
though confused by the recollection of his dream and 
dreading a recurrence. 

EPILEPTIC INSANITY 

Epileptic convulsions may occur at any age, but they 
frequently date from earliest infancy. They often leave the 
child feeble-minded or, at all events, changed in character. 
Epileptics who have had fits for years are not neces- 
sarily mentally affected, but many of them suffer from 
a mental deterioration, which presents special features. 
Weak-mindedness is commoner with them than mental 
aberrations. The patients lack initiative ; they are 
restricted in their ideas, and tedious in their expression 
of them. In their narrations they lose themselves in 
petty details, needless explanations regarding antecedent 
circumstances, and long digressions. They often make 
big plans and boast of what they are going to do, 
failing to appreciate their limitations ; others, less de- 
teriorated, are aware of their limitations, and chafe 
under their inability to undertake or accomplish anything 
outside of a very limited range. 

Unfounded aversions, especially towards their relatives 
or attendants, are common among epileptics, and tales 
of woe and ill-treatment are poured into the ears of 
strangers. Their power of attention is of limited range 
and easily diverted. They are highly religious—at least ? 



294 THE VARIETIES OF INSANITY 

they read the Bible diligently and pray a good deal. In 
religious and political opinions they always go to ex- 
tremes : they are rabid conservatives, or violent re- 
volutionaries, and fanatical proselytes of old and 
new religions. Their intellectual stock-in-trade becomes 
greatly reduced, and even limited to a few platitudes. 

The two most prominent features of the epileptic are — 
irritability, showing itself in attacks of temper or an un- 
pleasant peevish disposition, and impulsiveness, which 
may exist in every degree to the most dangerous acts. 
Conscious anger may pass into uncontrollable mania 
at any moment, and homicidal acts characterised by a 
blind, unreasoning violence may be committed under the 
varying conditions of complete or clouded consciousness. 

The really characteristic epileptic insanity is that 
appearing in connection with the epileptic attacks. This 
may appear before or after the paroxysms, or may re- 
place them ; thus we have pre- and post-epileptic in- 
sanity and the epileptic equivalent (psychic or masked 
epilepsy). The first named is not uncommon, and may 
show itself in exalted or maniacal conditions, or, as is 
more usual, in depression, fussiness, and fault-finding, 
appearing at varying periods prior to the convulsions. 
In some cases, also, there may be hallucinations of 
various kinds, sometimes disagreeable, but sometimes 
agreeable and even ecstatic visions or sounds are ex- 
perienced in this stage ; or there may be only an excess 
of irritability, gradually increasing to an explosion of 
violence and fits of destruction. In this last case the 
patient may be entirely rational, and endeavour to 
control himself till finally the condition culminates in 
an explosion of violence beyond his control, and often 
directly connected with the epileptic attack itself. 

In the psychic type of epilepsy the fit consists solely 
of the transient loss of consciousness, without convulsion. 
Not infrequently some of the worst phases of mania are 
the direct sequelae of a transient loss of consciousness 
without spasm. The subject of masked epilepsy and 
the consequent mania is replete with interest to the 
physician and the jurist, since such patients are prone to 
impulsive acts of violence and automatic states, in which 
the most complicated but entirely unconscious actions 



MENTAL AFFECTIONS OF CHILDHOOD 295 

and crimes may be carried out without premeditation on 
the part of the sufferer, being also out of all accord with 
his character during his intervals of mental health. 

Often there is nothing more than a clouded conscious- 
ness, and various acts may be committed automati- 
cally, of which there is complete forgetfulness after the 
attack. Thus, whilst wide awake, and in the midst of 
some occupation, the patient affected by such a seizure 
suddenly stops working, leaves the place in which he 
has been, and wanders about aimlessly until discovered 
and roused from his dream. A patient about to take 
a bath and seized by an attack may enter the water 
fully dressed, or while surrounded by people he may, in 
a fit, divest himself of all his clothing and do some 
strange and improper actions. More rarely his be- 
haviour is fairly orderly, and the series of his actions 
rather complex. Thus, he may go to the railway station, 
purchase a ticket, and make a long journey, stopping, 
changing carriages, and taking refreshments at proper 
times and places without attracting any special attention. 
When the seizure is over, he awakes as if from a dream, 
and has no recollection of what has happened. 

The post-epileptic mental disturbance is the most 
frequent of the three forms, and therefore the most im- 
portant. It is the rule that a fully developed epileptic 
attack leaves after it some temporary cerebral distur- 
bance ; most commonly there is a shorter or longer 
stuporous interval, or there may be a severe headache 
and more or less mental confusion. 

When, as a result of epilepsy, a real mental disorder 
develops, we note impairment of intelligence and of 
memory to a greater or lesser degree, incapacity for 
effective mental work, marked emotional instability, 
lack of inhibitory power, and a weak and forceless moral 
sense. Hallucinations of sight and hearing are also 
frequent. In their religious ecstasy, patients may receive 
imaginary messages and communications from the Deity. 
Often there are also delusions of persecution. In rarer 
cases we may see hallucinatory-confusional states, and in 
others extreme depression. But the epileptic furor is the 
most characteristic, and suggests in its phenomena some 
terrifying delusion or hallucination of the patient, or 



296 THE VARIETIES OF INSANITY 

some delusion of injury or attack by others. A peculi- 
arity of these cases is the fierceness and vindictiveness of 
their attacks on other persons, which seem often utterly 
beyond reason and out of character. 

The forensic importance of these various conditions is 
very great, and much stress must be laid upon the loss 
of consciousness as affecting responsibility. It should 
be borne in mind that, whether consciousness is lost or 
merely clouded, or if loss of memory only exists later, 
the condition is one of mental disease, and any remnants 
of self-control that may exist do not materially affect the 
case. Unfortunately, since the law regards them as free 
agents, forced seclusion is not usually possible until some 
deplorable incident has occurred. If a man has been 
subject to regular epileptic fits, and commits a homicidal 
act in an impulsive or motiveless manner, the presump- 
tion is very strong that the murder is a symptom of his 
disease, and he is not fully responsible for his actions. 



CHAPTER XXVI 

STATES OF ARRESTED MENTAL DEVELOPMENT 

IDIOCY, IMBECILITY, FEEBLE-MINDEDNESS, AND 
MORAL WEAK-MINDEDNESS 

Whereas in insanity we have changes in the mental 
capacity and dispositions of persons formerly normal, in 
the mental states which we are now about to consider — 
idiocy, imbecility, and feeble-mindedness — we have an 
arrested or defective development of the brain, and 
consequently a mental deficiency from birth or infancy. 



IDIOCY 

The most extreme form of mental deficiency is that of 
idiocy. It is a congenital condition in which the in- 
tellectual faculties have never developed, or at least not 
sufficiently. In dementia (Chapter XXII), in which a 
person may be intellectually reduced so as to resemble 
an idiot, a man is deprived of advantages which he 
formerly enjoyed. He was a rich man, who has become 
poor. The idiot, on the contrary, has always been, as 
regards his intellect, in a state of want and misery. 

Pathologically we may differentiate various types of 
idiots by putting in one class those who have heads too 
small for normal intelligence — i.e. microcephalics — and 
those idiots who have heads larger than the normal size — 
macrocephalics and hydrocephalics. Another class are the 
cretins, idiots of extremely dwarfed stature, with excessive 
breadth of the long bones in proportion to their length, 
and a doughy, yellowish skin. Still others, showing 
deformities of the skull, and long bones due to improper 
or insufficient nutrition in infancy, termed rachitic idiots, 

297 



298 THE VARIETIES OF INSANITY 

A further class are the paralytic and porencephalic idiots, 
who present paralysis from congenital or acquired defect 
in the brain substance; and yet another class, whose skull 
was compressed or injured on account of difficult de- 
livery or faulty use of forceps. 

The lowest type of idiot is one devoid of all under- 
standing, in whom is found an entire absence of intelli- 
gence. Being incapable of any reasoning power, he has 
no appreciation of the commonest physical dangers. 
His faculty of attention is also wanting, except a momen- 
tary attraction by loud noises, bright lights, and similar 
exciting objects. Of most of them it may be said that 
they do not appear to be conscious of their own existence, 
much less of ordinary feelings of pleasure, pain, fear, and 
love, except in the most rudimentary way. The sight 
of food alone has the power to draw them from their 
indifference, and they may show attachment to whichever 
person takes care of them, transferring their affection 
readily. There is no will-power, and no trace of the 
faculty of initiative. They have no power of expressing 
themselves by means of articulate language, but some 
of them succeed in making known their desires by certain 
signs, cries, or sounds, understood only by those in 
immediate attendance upon them. 

It is only in idiots of higher degree that we are able 
to determine voluntary attention, and by that to develop 
their general intelligence. As a rule they do not learn 
to read, but some of the more educable ones may learn the 
letters and make out some detached syllables, but they 
rarely get to the point of understanding the printed 
words. Even when we succeed in teaching them to read, 
their reading is staccato, sometimes sing-song, but never 
normal. Their writing, if at all possible, is still worse 
than their reading, for they lack the co-ordination of 
movement. Even when they succeed, they can write 
only from a copy, and never from dictation or spon- 
taneously. Calculation is impossible for the lower grade 
idiot, and even the higher grade learns only the elementary 
figures, and those with difficulty. 

Not having any or but little understanding, idiots 
rarely laugh, except when they laugh continually, as is 
the case with certain incurable idiots, who giggle con- 



ARRESTED MENTAL DEVELOPMENT 299 

stantly while making their balancing movements. They 
are extremely timid ; everything frightens them, because 
they cannot explain anything. Love of property exists 
sometimes to a considerable degree in higher class idiots. 
They do not hesitate to appropriate anything they want, 
especially if it be food, which more than anything else 
excites their desires. They are not naturally lazy, for 
they can be got to work if we know how to set about it, 
and they have been trained to it. They are only in- 
active from want of attention and slowness of conception 
and movement. The musical sense is often strongly 
developed in them, quite disproportionate to the other 
mental faculties, and not infrequently those who cannot 
speak at all can hum tunes correctly, so that parents base 
thereon sometimes false hopes that their child cannot be 
so very defective since he appreciates music. 



IMBECILITY 

The imbecile is one whose mental defect exists from 
birth or infancy, and is so great as to render him incapable 
of earning his own living, although he has intelligence 
enough to guard himself against the common physical 
dangers. 

In imbeciles we find defective mental powers of various 
degrees, from pronounced enfeeblement to grades of 
intellectual development, capable of fair education, but 
retaining a defect in some mental faculties. As a rule 
imbeciles are fairly conversant with their immediate 
surroundings ; they know their own names, and are able 
to respond to them when addressed. Their command of 
language, however, is extremely limited ; they are only 
able to pronounce a few words, or at any rate a few 
phrases, the correct significance of which they know. In 
imbeciles, voluntary attention exists within certain 
limits ; but it is intermittent, and they pass from one 
subject to another without there being any relation be- 
tween the two. Their memories are defective, and they 
do not retain from one day to another what they have 
been taught with care and trouble. Weeks and months are 
spent over the alphabet before it is finally, and then only 
imperfectly, mastered. The memory in imbeciles is 



300 THE VARIETIES OF INSANITY 

sometimes apparently greatly developed, but if we observe 
closely, we notice that they recite a piece always in the 
order in which they have learned it, and that the slightest 
interruption in the recital cuts it short, for imbeciles do 
not understand the sense of what they are saying. Their 
memory is therefore not a proof of intelligence. Such a 
memory cannot be utilised to any extent, for if im- 
beciles learn quickly, they forget with equal rapidity. 
It is difficult to educate them to read, and although 
some learn to write, they never form their letters well. 
They are unable to count beyond a certain number, 
and any but the most elementary arithmetic is en- 
tirely beyond their power. We usually succeed quite 
well in getting them to understand addition, but it is 
often very difficult to teach them what subtraction is — 
certain of them can never learn to understand it, even 
those who may be fairly well developed in other respects. 
The principle of multiplication is not understood, and in 
the great majority of cases division is impossible. Yet 
imbeciles have been known in whom the memory for 
figures was not only well preserved, but developed to an 
extraordinary degree. Some have a special memory for 
dates, and a perfect appreciation of past or passing time. 

Imbeciles are very much influenced by rhythm, hence 
they like music, and some can recite poetry, though 
they may not understand a word of it. 

Both idiots and imbeciles have often a good memory 
for tunes. They readily acquire simple airs, and rarely 
forget them. This is the more striking bepause of the 
utter absence of any other evidence of artistic taste. 
A beautiful landscape or a lovely picture is powerless to 
move them. In insanity too the musical faculty is often 
the last to go. Patients, incoherent in speech, unable 
to read a book, and no longer able to dress themselves, 
have yet been known to read music at sight and to play 
an instrument correctly. 

Some imbeciles reach a higher plane of mental attain- 
ments, and are capable of conversing correctly ; but their 
knowledge, as well as their vocabulary, is limited. Des- 
pite the apparent facility of language, thought is really 
slow. Patients of this class do not comprehend quickly, 
and there is a frequent tendency to the repetition of any 



ARRESTED MENTAL DEVELOPMENT 301 

question addressed to them. They sometimes seize 
readily upon anything that is grotesque in a person, and 
may express it in comparisons which are really quite droll, 
and which make them appear to be more intelligent than 
they really are ; more often, however, these compari- 
sons are absurd and trivial or vulgar. Some of them 
exhibit a wonderful power of repartee and a dry form of 
humour, all the more surprising on account of its un- 
expectedness. The credulity of imbeciles, as might be 
expected from their want of understanding, is very great. 
They are very egotistic, and occupy themselves above all 
with their physical well-being. They are easily disturbed 
by the least physical pain which they suffer, and give 
expression to it in a lively manner. Similarly they 
manifest joy in a noisy manner, out of all proportion to 
the cause of it, getting more and more excited, and some- 
times not even knowing why they laugh. They often 
laugh without motive, even perhaps under sad circum- 
stances if some little thing which they think funny 
attracts their attention. 

Imbeciles are fundamentally lazy, unless some special 
inducement is offered to move them, rewards that they 
love or punishments that they fear. They are often vain, 
quarrelsome, easily irritated, and a source of annoyance to 
the household from their propensities to lying, thieving, 
and their general shamelessness and uncontrollable 
character. They are capable of manifesting a certain 
degree of affection to those who treat them kindly and 
with whom they live ; but the feeling is never profound. 
They are amenable to a certain amount of training and 
discipline in the direction of their external behaviour. 
If left to themselves, their actions and manners become 
so repulsive that it is impossible to live in their society ; 
but if properly trained, they learn to dress themselves 
decently, to eat inoffensively, and to control their animal 
instincts. 



the Feeble-minded 

The criterion employed to distinguish the feeble- 
minded from those on the next lowest stage — i.e. im- 
beciles — is capability, in favourable circumstances, of 



302 THE VARIETIES OF INSANITY 

earning a livelihood ; while on the other hand the 
feeble-minded are distinguished from the normal by 
their incapacity from the earliest age to compete with 
others on equal terms, or to manage themselves or their 
affairs with ordinary prudence. In my book on Scientific 
Phrenology I have given ample illustrations to indicate 
that the size and shape of the head are often sufficient 
to determine the existence of mental weakness. 

This class includes the great number of backward 
children, who are the cause of endless trouble and anxiety 
to parents. One of the commonest defects is in the 
power of attention. Those in whom this power is 
wanting are unable to concentrate their minds upon 
anything for long. They cannot persevere with a piece 
of work, or read a few pages of a book, or keep up a 
sustained conversation on one subject — the least thing 
withdraws their attention elsewhere. 

They are slow of apprehension, dull-witted, deficient 
in ordinary interest, in judgment, and in common-sense. 
In a certain sense it may be said of them that they do 
not grow old with their years. They remain childish, 
easily satisfied with trifles, and display interest in things 
which have long ceased to interest normal people of the 
same age. 

They cannot see why they should learn something for 
the sake of future benefit ; all they care for is immediate 
gratification. Hence, they lack application ; as soon as 
they tire of one thing— and they do so quickly — they 
take up another. So the youth grows up, and when he is 
of an age at which others have made some progress in a 
definite career, the mentally defective is still undecided 
as to his aim in life. 

Sometimes there is artistic talent ; the lack of applica- 
tion may then be overlooked by the parents. This class 
of mental defectives may draw, paint, sing, play, write 
verses, and make various pretty things with easy dex- 
terity. Their lack of industry prevents them from ever 
attaining mastery of the technique of any art. They 
exhibit plenty of artistic taste and feeling, but they are 
always amateurs ; they are never really good. Before 
they can be commended, allowance must always be made 
for this and for that. 



ARRESTED MENTAL DEVELOPMENT 303 

They may be excellent company, pleasant companions, 
good-natured, easy-going, and urbane, but they fre- 
quently have one peculiarity : their self-conceit is not 
inordinate, but remains undiminished in spite of their 
repeated failures in the most important affairs of life. 
The normal effect of failure, especially in important 
matters, is to depress ; it produces dejection, diffidence, 
lack of self-confidence and of self-reliance. But the 
people here described are continually failing — their lives 
are one long record of failure; yet they are not only 
cheery and content, but their confidence in their own 
powers, in their business aptitude and general superiority 
to other people, remains undiminished. 

The feeble-minded youth may be capable of receiving 
some education, and may be even brilliant in some sub- 
jects. While he is at school, all may go well ; but as soon 
as he attempts to take his place in the outside world, his 
lack of mental balance becomes apparent. The normal 
man, with his clear-minded, logical thought, sound judg- 
ment, and strong will, sees where the feeble-minded only 
gropes ; he plans and acts, where the latter only dozes 
and dreams. 

With quiet and uneventful surroundings which do not 
overtax their mental energies they manage to pass through 
life in the undisturbed possession of their meagre mental 
outfit with comparative ease and comfort, but the 
moment they are subjected to complex conditions of 
life, which require greater mental and physical activity 
to gain a subsistence, they weaken and falter by the way, 
and gravitate to the vagrant and pauper ranks. 

To earn a livelihood needs persistent industry. It re- 
quires such self-control, such self-denial, and such a 
degree of self-abnegation as will allow of the steady 
pursuit of an uninviting and perhaps repellent employ- 
ment, in spite of the solicitation of others by which 
immediate pleasure may be gained. It means, in short, 
the postponement of immediate pleasure, to be enjoyed 
in the future. But of such patience and perseverance 
the feeble-minded has usually next to none. 

Some feeble-minded persons, however, are placid, well- 
behaved, and industrious ; but the life of these persons 
is one of conformity to habit, and not to ideals. They 



304 THE VARIETIES OF INSANITY 

rarely think of, much less make plans for, the future ; 
and the few who have vain imaginations of what they 
would like to do or become are lacking in the necessary 
intelligence or will to direct their attentions accordingly. 
Indeed, one of the most pronounced features of the 
feeble-minded person is his utter lack of purpose. If 
given work and told exactly what to do, he may often 
be trusted to do it ; he may even acquire the habit of 
performing the same task day after day, year in and year 
out, without supervision. But the work must be strictly 
of a routine nature, for he would be quite unable to cope 
with any unforeseen emergency. The lighter grades of 
feeble-mindedness often fail of recognition, but as soon 
as some unusual situation arises, demanding discretion, 
decision of action, and self-control, incapacity becomes 
evident. And should he lose his employment, he is 
incapable of any strenuous attempt to seek other. To 
use a homely phrase, we may say that the bread of these 
persons must be put into their mouths. 

Feeble-mindedness appears in all ranks of life, pro- 
bably as frequently among the well-nourished and well- 
to-do as among the poorly-nourished and penurious. 
The feeble-minded of the upper classes are better cared 
for and protected than those of the poorer classes, and 
are less in evidence, not being called upon to compete 
with their fellow-men for a living. 

The ability to administer the means, when gained, is 
of equal and even of greater importance than the 
ability to earn a livelihood ; for, while the first is obliga- 
tory upon every one, there are many people who are 
relieved by the exertions of their predecessors from all 
needs to earn their own livelihood. Defect in the ad- 
ministration of the means may be due to general 
defect of intelligence, so that the subject of it is unable 
to appreciate the amount of his income, unable to grasp 
the relative values of different commodities, unable to 
appreciate the different purchasing power of different 
sums of money, so that he is at the mercy of any dis- 
honest person who chooses to ask him half a sovereign 
for an ounce of tobacco or a box of matches, or to palm 
off upon him a coloured lithograph as a genuine Raphael, 
a broken-winded screw as a certain winner, ormolu and 



ARRESTED MENTAL DEVELOPMENT 305 

glass as gold and diamonds. In consequence he ex- 
pends his income and sinks into debt from sheer inability 
to appreciate the relation between income and outgo. 

Another defect is the inability to say "No." There 
are very many persons of weak character who are unable 
to withstand solicitation, who give to every beggar and 
lend to every ■'* sponge " money which they cannot well 
afford, from lack of moral courage, force of character, or 
strength of will to refuse. These are the people who are 
ruined by endorsing bills and becoming security for their 
friends ; who buy worthless shares forced on them by 
unscrupulous agents or financiers ; who make collections 
of antique furniture, pictures, etc., which are manu- 
factured specially to delude the unwary. They are the 
people whose wills are disputed on the ground of undue 
influence ; who make wills or deed of gift in favour of 
their nurses or landladies, to the exclusion of their own 
near relatives. 



MORAL WEAK-MINDEDNESS 

The feeble-minded often have vicious and criminal 
instincts, and even the well-behaved mentally defective 
may drift into crime, being often easily led. Their 
respectability will depend upon their position in life, 
their environment, and associates. 

Not all weak-minded are criminal, but they lack the 
capacity to acquire the elements of good or social conduct, 
and it is this incapacity to develop the higher and more 
complex associations, and not any specifically vicious 
tendency, that makes them succumb to the temptations 
of an evil environment. 

That those who are mentally feeble should show moral 
deficiencies is only natural, considering that the lower 
the intellect, the feebler the control over the instincts 
and passions. But there are a class of men who, though 
for a time at least they may possess brilliant intellectual 
abilities, lack, through some innate defect, the highest 
human acquisitions, the ethical and altruistic sentiments, 
and who manifest from an early age highly active pro- 
pensities to vice and crime, and on whom punishment has 
little or no deterrent effect. 

20 



306 THE VARIETIES OF INSANITY 

Under such " moral insanity " or " moral imbecility " 
we do not include any of the acute or chronic insanities 
already mentioned, in which tendencies to vice and crime 
may be manifested simply as a symptom of their disease, 
insane conduct arising from insane ideas. Nor do we 
mean the idiots and imbeciles just described, who are so 
deficient in intellect that they cannot appreciate moral 
conduct. We mean such subjects only who, while 
intellectually to all appearances normal, from the time 
when a child should show moral capacities are already 
different from other children, -and whose anti-social 
nature ill fits them to take their place in the community. 
Their essential characteristic is a lack of power to recog- 
nise ethical distinctions, and through this moral depri- 
vation there is a serious lack of balance between the 
thinking and acting capacities. These patients are 
rarely seen in asylums, and since they are held legally 
responsible for their acts, many of them find their way 
to prison. 

The "morally weak-minded" are persons whose mental 
development stopped short when it reached the altruistic 
sentiments (see Chapter V). These higher attributes of 
human nature do not exist in them. The intellect of 
these patients is tolerably developed, and they possess a 
certain amount of knowledge, which they may exploit with 
some craftiness. Their memory and reasoning power may 
be up to the average, but their views are narrow, and 
they do not concern themselves about their future. 

The symptoms first appear in infancy ; the moral 
development does not take place as in normal children ; 
they lack natural affection, are especially rebellious to 
authority, brutal and cruel, and unreliable in all respects. 
The moral development of a child is, in all cases, largely 
a matter of education; but these cases lack the basis that 
is essential to a moral sense. There is no material for 
moral development. Such children, lacking the elements 
of the moral perception, seem incapable of distinguishing 
between truth and lies, so that their statements on the 
most ordinary matters of fact are never believed. They 
steal systematically, and have no sense of shame. There 
is a lack of sympathy, as shown by barbarous cruelty to 
animals, malicious teasing, ill-treatment of their play- 



ARRESTED MENTAL DEVELOPMENT 307 

mates, unresponsiveness to kindness. Other cases are 
less extreme ; the moral potentialities are there to a 
limited extent, and while these children are wayward and 
hard to bring up in a respectable way, they are not 
absolutely incapable of learning self-control and appre- 
ciating the higher motives of conduct in some measure. 

Attempts at education are fruitless, since the most 
important incentives, love and ambition, are lacking. 
Force alone is able to suppress the manifestations of their 
unbridled selfishness, but this is soon met by duplicity, 
cunning, deceit, callousness, and stubbornness. Such 
children of the well-to-do classes shock their parents at 
an early age by vulgarity, lying, persistent laziness, petty 
larcenies, and peculations. They wander from one 
teacher to another, always with the same lack of success, 
until finally it becomes impossible to protect them from 
the results of their conduct. 

They are likely, even as adults, to be always moral 
weaklings, quick to yield to temptations that would be 
resisted by a healthy minded man. When these cases 
are intellectually bright, so that they can fully appreciate 
utilitarian considerations and control conduct according 
to them, they may become the sharp, unscrupulous 
swindlers or business or professional men, whose only 
guide or restraint is expediency and safety. The moral 
sense, sympathy, pity, love, etc., are conditions utterly 
strange to such men. They act from cold calculation. 
Selfishness and heartlessness mark all their acts. To 
the murderous burglar, callousness is a far more necessary 
article of equipment than a jemmy or a loaded revolver. 
If a man is going to think how unfair it is to the victim 
to have his brains battered out for attempting to defend 
his property, he had better renounce that line of business. 

Another characteristic is that these subjects are never 
penetrated by a feeling of their guilt, or very evidently 
show repentance. They may perhaps feel and dread the 
material consequences of crime, but they are deficient 
in the feeling of moral guilt. Only those men and women 
whose active animal propensities are governed by sound 
moral sense will, when having committed wrong for once, 
feel the torture of conscience in the loneliness and dark- 
ness of the night, and be afflicted With those terrible 



308 THE VARIETIES OF INSANITY 

dreams which are alleged to nightly shake the guilty soul. 
Not so the moral imbecile. His conscience is not strong 
enough to torture him. 

It is unfortunate that the notion is still so prevalent 
that all persons are equally good by nature, and might 
be equally good actually had they but the will to be so. 

Men are born with all degrees of moral capacities and 
incapacities, and some of them wholly lacking in that 
regard, just as they are born with all degrees of intellectual 
endowment, and some of them with none whatever. A 
man may be an idiot morally, as well as intellectually. 
We have shown that there are in man propensities which 
under certain circumstances, that is by over-excitation, 
without the guidance of intellect and moral power, may 
produce evil inclinations and give rise to injurious acts. 
Let the admirers of the excellence of the human species 
reflect why, in all ages and in all countries, robberies and 
murders have been committed ; and why neither educa- 
tion, legislation, nor religion, the prison, hard labour, 
nor the wheel, has yet been able to extirpate these crimes. 
In Queen Elizabeth's time, out of every thousand persons 
born, five were actually hanged, as a matter of recorded 
statistics, yet it did not eliminate crime. Do criminals 
rob and murder for the sole pleasure of exposing them- 
selves to punishment, and without any temptation ? 
Suppose we allow it to be education, and not nature, that 
produces vicious tendencies, the difficulty still remains 
the same, because education does not depend upon him 
who receives it ; and education never would develop 
either good or evil inclinations, were not their germs 
previously existent in human nature. 

One of the qualities which such subjects lack is self- 
restraint — i.e. the power of foregoing immediate gratifica- 
tion. In determining whether a vicious act is done by a 
sane person or a feeble-minded one, we must possess a 
fairly full knowledge of the previous character, and 
estimate the degree of enormity by the gravity of the 
difference between the pleasure that is gained by imme- 
diate indulgence, and the benefit that is forfeited with the 
certainty and magnitude of the evil that is incurred. 

Another quality which such subjects lack is the sense 
of responsibility. They are as truly insensible to the 



ARRESTED MENTAL DEVELOPMENT 309 

moral relations of life, as deficient in this regard as a 
person colour-blind is to certain colours, or as one without 
ear for music is to the finest harmonies of sound. 

Such diagnosis is facilitated in a certain number 
of cases by the periodicity of the morbid impulses. 
Thus I have seen quite a number of young men, of 
normally clean, sober, and chaste life, who were at- 
tacked from time to time, at intervals usually of a few 
months, with an overpowering -desire to kick over the 
traces. In some cases the desire is merely for drink ; 
in others it is not for any dissipation, but merely for 
a life free from the conventions and restraints of civilisa- 
tion. Whatever the particular craving may be, it comes 
on very rapidly, and is so powerful as to be, in most 
cases, irresistible. The paroxysm is short-lived, and 
after a few days, or a week, they return to decency and 
propriety, and live an exemplary life until, after an 
interval of a few months, the fit seizes them again. When 
they are closely examined, such people often deny — and 
there is no reason to doubt the denial — that they have, 
when they break out, any pronounced craving for drink 
or for any other indulgence. What they experience is a 
horrible, ill-defined, voluminous, indescribable, and tin- 
bearable sense of uneasiness. 

We recognise feeble-mindedness in the gilded youths 
who live for the moment, who have no serious thoughts 
for the future, are selfishly unmindful of others' rights, 
interest, convenience, and pleasures ; who live to eat, 
drink, dress, study the musical comedy, with its lady 
performers, and are addicted to vices or become the 
victims of impostors. We see it in the rowdies, ine- 
briates, spendthrifts with no money sense, and hosts of 
other people whose early life promised well, but who 
disappointed the expectations of fond patents and 
friends, and descended in the social scale. 

Depravity of all kinds is frequent with persons possess- 
ing normal brains, but experience teaches us that a large 
proportion of the petty thieves, pickpockets, individuals 
convicted of indecent assaults and moral crimes, are of 
low mental order ; are deficient in brain development ; 
have not the capacity under the best of circumstances for 
taking advantage of ordinary school education, and are 



310 THE VARIETIES OF INSANITY 

often incapable of making a living for themselves ; and 
eventually become a care and a burden to the community. 
The Report of the Royal Commission on the Care and 
Control of the Feeble-minded contains the following 
figures : From 45,000 to 50,000 of the school children, from 
one-fourth to one-fifth of all the inmates in workhouses, 
one-tenth of the prisoners, about one-half of the girls in 
rescue homes, one-tenth of the tramps all over the 
country, and two-thirds of the inmates of homes for 
inebriates, are mentally defective. 

To the sociologist, the problem of feeble-mindedness is 
a crying one. The idiot by natural tendencies dies out 
in his generation ; not so the higher grade imbecile, 
whose procreative instincts are not infrequently ab- 
normally developed, and who, unrestrained by any moral 
code, begets his kind in ever-increasing numbers. 



CHAPTER XXVII 

INSANITY AND THE LAW 

THE CRIMINAL INSANE AND THE INSANE CRIMINALS 

The ordinary sane criminals may be divided into three 
classes : 

(i) Those who, not being really Criminally disposed, 
have fallen at some moment of temptation in consequence 
of the extraordinary pressure of exceptionally adverse 
circumstances. They have committed a single crime, 
which they are never likely to repeat; but the law punishes 
them by way of warning, and an example to others. 
Their crime is a chance crime, and the main effort ought 
to be to save the first offender. 

(2) Those who, having some degree of criminal dispo- 
sition, might still have been saved from crime had they 
had the advantage of a fair education and of propitious 
conditions of life, instead of the disadvantages of an evil 
education and of criminal surroundings. These are the 
criminals whom every effort should be made to reform. 

(3) The born criminals, whose instincts urge them 
blindly into criminal activity, whatever their circum- 
stances of life, and whom neither kindness, instruction, 
nor punishment will reform. This class furnishes the 
professional criminal, who deliberately seeks crime, 
whatever his opportunities for earning an honest living, 
and the one main thought must be to protect the com- 
munity against them. 

The first time a man is in prison often by accident ; 
the second time it shows some leaning towards vice ; 
and if he comes a third time, it is almost a certainty he 
will return. 

This last class forms the typical criminal, who is born 

3" 



312 THE VARIETIES OF INSANITY 

in crime, born into crime, and whose vocation is crime, 
by a physical and psychical proclivity ; they are men in 
whom the selfish tendencies predominate over the moral 
and religious sentiments and altruistic motives, and 
whose intellectual powers, instead of inhibiting such 
tendencies, are employed to further them and to supply 
means for their gratification ; moreover, such men are 
usually not influenced by domestic affections, and much 
too insensible to the esteem of others to be prevented 
from committing crime. Investigations have been made 
which show that in this type of men, not only the moral, 
but also the physical sensibility is much diminished, and 
that they are less susceptible to pain than normal men. 

That they are not amenable to moral treatment is 
shown by the frequent recommittals and by the apparent 
absence of all remorse. According to the evidence of 
night-watchers of prisoners, they sleep as soundly as the 
rural cottager, the simple peasant, or the most innocent 
in the quiet homes of social men. Repentance is rare. 
All the appliances of chaplains and teachers, with all the 
discipline of prison legislation, fail to turn them from 
the error of their ways. One cannot make an old fox 
into a house-dog, and one cannot make an honest working- 
man out of an old thief. The criminals who do sincerely 
repent are those who have been drawn into crime through 
imprudence, or an unfortunate fit of passion, poverty, 
and sore need, or from other very pressing external 
circumstances. When the fatal occurrence of circum- 
stances has passed, the milder inner feelings become 
active. This is what usually occurs in the case of crimes 
committed in a fit of passion. After the event, total 
contradiction is manifested between the natural senti- 
ments and the act committed, and this contradiction 
is what constitutes repentance, or the natural conscience. 
(See also Moral Weak-mindedness in previous chapter.) 

It is commonly taken for granted by lawyers, that if 
a rational motive can be found for the criminal offence, 
such as lust, rage, greed, or any other passion, there is 
no ground to allege insanity, or, at any rate, no ground 
to allege exemption from responsibility by reason of 
insanity. In the eyes of the law the actual madman acts 
without motives or acts from insane motives. But 



INSANITY AND THE LAW 313 

insane persons have the same feelings and passions as 
those who are not insane, only they are not restrained 
to the same extent as normal persons. 

The difference between the madman and the criminal 
is that the one cannot and the other will not exercise 
self-control. The one is to be pitied, the other must 
be blamed and punished. 

We are not all alike in our organisation or our educa- 
tion ; the problem of life is easier for one than for another ; 
some of us have more temptations than others — but 
this does not compel us to yield to them. So long as 
a man is himself — so long as he is not a madman — he has 
at every point the power to say " Yes" or " No." He 
can, in other words, exercise self-control and self-denial 
if he will. Only it is difficult sometimes to settle exactly 
when this self-determining power ceases and real insanity 
begins. There is a perennial conflict between lawyers 
and the medical profession as to the responsibility of 
those who are on the borderland of sanity. The lawyer 
is a very useful person to rind out whether or not the 
crime has been committed by the criminal, and whether 
the evidence of his past history is deposed to by truthful 
witnesses or not ; but the mental expert alone can satisfy 
himself as to his true characteristics, and the best 
method of treatment. 

Whether a man is mad is a medical question, upon 
which the judge wants our advice. Whether he is 
responsible is a legal question on which we can throw 
light, but the decision of which concerns the lawyer. 

The expert should properly seek to determine in his 
own mind whether the person was insane, as he would do 
in his consulting-room, or in his hospital, and as all 
authorities approve. He may seek to differentiate be- 
tween mental disease and an act performed in an ebullition 
of anger, jealousy, envy, or other unconquered passion, 
which for the time had the mastery, or whether the deed 
done was that of an insane person, with criminal ten- 
dencies and selfish motives. He may even take note arid 
report on the influence of heredity and environment of 
the accused, and any temporary circumstances that may 
have helped to determine the act. But it should not be 
the expert's business to determine the degree of legal 



314 THE VARIETIES OF INSANITY 

responsibility of the accused. That should be the business 
of the lawyers, after they have heard the expert's evidence. 

There are mental states that may modify responsi- 
bility in some degree, though they do not wholly excuse 
a crime or violation of laws that are established for the 
protection and welfare of society. It is for the expert 
to state his case as fully as medical and psychological 
knowledge enables him to do, but the conclusion as to 
culpability may be left safely to the magistrates or judge. 
That the medical evidence should be made the subject 
of argument between two opposing counsel, and the 
sanity of the criminal should be left to be determined 
by twelve inexperienced jurymen, is an antiquated pro- 
ceeding which has little to recommend it. 

In this country, the question of the commission of a 
crime and its excuse on the plea of insanity are the joint 
subjects of our judicial investigation at the trial of a 
prisoner. But this is not the case in other countries ; 
notably it is not the practice in France, where the code 
of procedure enacts that when the magistrate, during the 
examination, perceives, or is informed by attested cer- 
tificates, that the person accused of crime does not enjoy 
the full measure of his intelligence, he is to suspend his 
examination and to make an order by virtue of which one, 
two, or three experts are requested to examine the ac- 
cused. These experts, having been sworn, examine 
into the particulars of the crime and the prisoner's 
history, and they examine the prisoner himself as often 
as need be, either in prison or elsewhere ; and they can 
even have him removed to a lunatic asylum for the pur- 
pose of prolonged observation. If they report that the 
prisoner is insane, the magistrate generally accepts their 
verdict as final, and issues an order of non lieu, or no 
jurisdiction. Upon the report of these experts, or on 
the report of another set of experts whom the court has 
the power of appointing if not satisfied with the first, 
depends whether the trial for the crime itself does or 
does not take place. But at the real trial the question 
of irresponsibility cannot be raised. Practically the 
same system prevails in Austria, and some other Euro- 
pean countries. 

Under the English system, the mental condition of a 



INSANITY AND THE LAW 315 

prisoner on trial is too often decided in court, upon the 
partisan evidence of medical witnesses who sometimes 
contradict each other ; or, in ordinary prosecutions 
where the prisoner is undefended, he may be found guilty 
by the jury on the evidence of sanity or insanity pre- 
sented to them by the prison doctor. Prison is not a 
suitable place for the observation of lunacy. Such a 
procedure has long ago been discarded in many of the 
American States, and in Germany, where special facilities 
for observation are provided. 

It is a settled law that every one is assumed to be 
sane until the contrary is proved, and the burden of 
proving that an offender is insane lies upon him who 
asserts it ; but an offender having been proved to be 
insane, I agree with those who hold that the burden of 
proving that his insanity had no connection with the 
offence with which he is charged should lie upon the pro- 
secution. I think that this would better serve the ends 
of justice than the present method, by which the 
defence must prove not only that the prisoner was in- 
sane at the time the offence was committed, but that 
the insanity was of such a character as to deprive him of 
the knowledge of the nature, quality, and wrongness 
of the act. Even, however, if the suggested rule of law 
were to be substituted for that in existence, it would be 
far from covering all cases, for many offences are com- 
mitted by persons whose minds are temporarily dis- 
ordered, but who are not insane in any but a technical 
sense, which would probably not be admitted in a court 
of law. 

If there were not the difficulty between the medical 
recognition of insanity and the legal definition of it, 
criminal lunacy would be largely preventable, for there 
would not be so much delay in the registration and 
treatment of insane persons, nor so much premature 
release of men under treatment. The number of crimes 
and attempted crimes that result from these two con- 
ditions is very considerable. There are walking about 
in our midst plenty of potential criminal lunatics whose 
insanity is not recognised. Nobody knows when it may 
be his turn to enact the part of victim in a realistic drama 
of blood. How often do we read reports of inquests of 



3i6 THE VARIETIES OF INSANITY 

murder and suicide ! Often not much notice is taken 
of these cases, because the accomplished deed having 
had a sobering effect on the criminal lunatic, he, in a 
great number of cases, turns the weapon upon himself. 
How often, too, does a patient who behaved admirably 
while under restraint, attempt murder or self-destruction 
on the very day of his release ! 

All these difficulties arise because of the great differ- 
ence between the medical and legal interpretation of 
insanity. The legal interpretation of insanity is too 
high, and so the object of all lunacy legislation from a 
public standpoint is defeated, namely, to prevent the 
lunatic from becoming actually dangerous to himself 
and others — to prevent him, in short, from becoming a 
criminal lunatic. No stronger confirmation of the 
truth of this is needed than that as many as 89 per 
cent. — or let us say the great bulk — of the crimes of 
criminal lunatics are crimes of violence. 

Mental physicians maintain that the existing law is 
wrong, and that it is not in accbrd either with our 
practical experience or with the advance of mental 
science. The legal profession answers that their duty 
is simply to act in conformity with the law as it stands, 
yet we are all animated with but one desire — that 
justice be done to the unfortunate criminal whose mental 
disease has either directly or indirectly caused his 
criminality ! 

Now, what is the law which we so generally condemn ? 
We can sum it up in this one question : Was the accused, 
at the time of the committal of the act, labouring under 
such a defect of reason, or disease of mind, as not to 
know the nature and quality of the act he was com- 
mitting, or that he was doing that which was wrong ? 
This is the question the judge has to put to the jury, 
and it is to this question only that medical experts 
have to formulate an answer, and prove by facts elicited 
by them or sworn to by witnesses. 

The criminal is assumed to be conscious of the nature 
and quality of his acts, to know that they are injurious 
or noxious and worthy of punishment, and to be 
able to control them. An insane person may cause the 
same injury to society as a criminal, but, seeing that he 



INSANITY AND THE LAW 317 

is not able to control his acts, or is impelled by some 
false idea for which he is not responsible, or is ignorant 
of the nature and quality of his act, and its consequences 
to himself and others, he is not punished. In the one 
case the person is supposed to be able to recognise 
right and wrong, and to act accordingly ; in the other 
case he is not able so to distinguish and to decide. 

There are comparatively few madmen of whom it 
can be truthfully said that they have no proper know- 
ledge of right and wrong. They often do wrong by reason 
of their mental disease, but most of them know at the 
time that such act is wrong and against the law of the 
land. They may have the power of distinguishing right 
from wrong, but they have not the power of choosing 
right from wrong. They are often conscious of doing 
wrong, but have not the power to stop the brain machi- 
nery which impels them so to act ; they lack the self- 
control. They are often the slaves of a conception which 
they not only cannot check, but they may even devise 
subtle means of carrying the conception into action. 

Taking even sane persons, it must be apparent to 
the most ordinary observer that the majority of authors 
of violent and reckless crime, especially homicide, man- 
slaughter, and serious assaults, are under such influence 
of passion as to obscure reason and reflection for the 
time being, and that they are not thinking at all at 
that moment of the consequences of their acts, or that 
they are doing wrong. Whether a jealous liusband 
shoots his wife's lover to vindicate his own honour, as 
sometimes happens in France, or a burglar stabs a police- 
man in order to prevent himself being arrested, as 
sometimes happens in England, each may be, at the 
time of the act, incapable of distinguishing right from 
wrong. In the first case the thirst for revenge, in the 
second the desire for liberty, completely deadens the 
moral sense. 

At the back of human nature, and no doubt existing 
as a survival qi ancestral conditions, we often have 
obscure tendencies towards killing, torturing, destruc- 
tiveness, appropriation, misrule, irritating and teasing 
others, " cussednesses " of every sort, which sometimes 
will show themselves in spite of Christianity and in 



318 THE VARIETIES OF INSANITY 

defiance of morals. These feelings and obsessions in 
such persons are always worse when health is bad. The 
suddenness of the temptation or irritation makes a 
great difference to its being yielded to or resisted. If 
you suddenly strike, most men will automatically return 
the blow. Place cold water before a man dying of 
thirst, and he will take and drink it, if it was fifty times 
the property of another man. Take a person in anger, 
he may hurl words at his antagonist, which he has cause 
to regret when regaining his equilibrium, he may even 
strike him, and appreciate his own act only after it 
has been executed. Thus, even a sane person is not 
always sane — that is to say, he can be guilty of insane 
acts. 

How unsatisfactory the legal test is may be shown 
by the following example : A man who has led a steady 
and consistent life, one tenderly attached to his wife 
and family, respected and esteemed by his neighbours 
and friends, without any conceivable motive, possibly 
without manifesting even any premonitory symptoms 
indicative of mental derangement, and it may be without 
any traceable hereditary tendency thereto being dis- 
coverable, rises in the night, murders his wife and chil- 
dren, and probably attempts his own life. Should the 
unfortunate man succeed in self-destruction, but little 
difficulty then is found in arriving at the verdict of 
temporary insanity ; but if he survives to take his trial, 
the plea of insanity may fail, and the madman will be 
left for execution, unless sufficient interest be excited 
to procure a reprieve of the sentence. 

We ought to inquire in all criminal cases into the 
individual history. Often there has been some injury 
to the head affecting the brain, and consequently the 
mind and character. Let the reader compare the fol- 
lowing two cases : 

ist Case. — After being two years married, a working 
couple had to live separate because the man was out of 
work, but they actually visited each other. He was fond 
of his wife, and had no reason to complain of her, only he 
did not want her to work for his living as well. According 
to medical testimony, this man had been thrown from a 



INSANITY AND THE LAW 319 

horse, with his right temple against a stone wall, so vio- 
lently that he remained unconscious for a month, It was 
thought then that he would become of unsound mind. 
His general demeanour had altered, but not much. 

Four years later this man received a second severe 
injury, when he fell from a ladder, again on to the 
temporal bone. He now was considered " cracked," 
and had to take inferior situations, such as a potman's. 

In the midst of affection he one day cut his wife's 
throat. While under sentence of death he told the 
clergyman that he had murdered his wife because another 
woman had said she was unfaithful. Like an imbecile 
person, he believed it at once without inquiring into its 
truth. 

An injured brain is unable to stand alcohol. This 
man, it was shown, was drunk before the murder, and 
the judge declared : " If a person by drinking deprived 
himself of his senses, and whilst in that state committed 
a crime, he could not plead the insanity of drunkenness in 
justification, because he voluntarily deprived himself of 
the power of his actions." This man was hanged. 

The second case is one from my own experience : 

G. W., a young man, received a blow on the temple 
from a cricket ball. He was knocked down, and re- 
mained insensible for several hours. For several days 
after the injury he remained dull and stupid. Slight 
spasmodic twitchings of the leg and arm were noticed 
on the opposite side to that injured, and at the same 
period a daily and increasing change of character. 
Before the accident he was kind and affectionate in his 
manner, and particularly attentive to the commands and 
wishes of his parents ; but now he became spiteful, re- 
vengeful, and perfectly reckless. He was constantly 
quarrelling with his brothers and sisters. If requested to 
perform a duty, he became impertinent ; and if checked 
in the least, he swore and used the grossest language. 
He was extremely mischievous. He destroyed the 
furniture whenever he had the opportunity, and did harm 
to his younger brothers and sisters. He was detected in 
an attempt to fire a quantity of wood in the cellar of 



320 THE VARIETIES OF INSANITY 

his father's house. He threatened to kill the whole of 
his family with a mallet, and seemed to enjoy the terror 
of his relations when they became alarmed at the de- 
structive nature of his actions. 

Physically he appeared quite well. He answered 
questions with the greatest composure and intelligence, 
but the moment he returned to his own home and was 
left uncontrolled, his actions became violent in the 
extreme. 

This patient got well after treatment. Supposing he 
had been older and left to his own resources without 
supervision, he might have killed some one, and, accord- 
ing to the justice exercised in the. previous case, he too 
would have been hanged. Yet who will say that there 
is any marked difference between the two cases ? The 
difference is one of degree only. Both were morally 
irresponsible for their actions, if not legally so. 

The legal view of insanity is that it is a disorder of 
the intellect. It ignores the emotions and volition. But 
no one can be said to be of sound mind unless all the 
mental functions — intellectual, emotional, and volitional- — 
— are healthily performed. The legal test of insanity 
is simply a test of knowledge, whereas any one acquainted 
with diseases of the brain must be aware that the dis- 
order expresses itself not only in perverted ideas, but in 
all sorts of perverted feelings, appetites, and instincts. 
The law does not embody that, but fortunately in 
practice it is often allowed. It is by no means unusual 
to find the disorders of the emotions and volition out of 
all proportion greater than the disorder of the intellect, 
and this is especially the case in regard to those victims 
of insanity who are most likely to bring themselves 
within reach of the criminal law. It is a common 
experience in lunatic asylums to find that the very 
persons who are most dangerous to themselves and those 
about them are the most intelligent inmates in the 
institution. 

It is very difficult to perceive the motives of human 
action and to prove they are morbid, if behind the emo- 
tional stimulus there is no delusion or intellectual de- 
ficiency. Not only is there such a state as constitutional 



INSANITY AND THE LAW 321 

immorality in an otherwise sound person, but in the 
early stages of insanity the psychosis may be slight, 
having only just begun, and a certain lucidity preserved, 
yet the patient may display a shocking degree of im- 
morality in his feelings and conduct. In such instances 
the faults of character are out of proportion to the 
intellectual defects. The public are very ready to cast 
the stigma of insanity upon any one who talks foolishly, 
but hesitate to confer it upon the person who commits 
foolish acts. 

Amongst persons of undoubtedly unsound mind we 
have the hypomaniac (Chapter XVIII), who may reason 
so ably that he gives the impression of being saner than 
in his normal state. The melancholiac (Chapter XIX) 
also reasons clearly, and his depressed condition may be 
mistaken for the outcome of remorse for the crime. The 
paranoiac (Chapter XXI) will defend his misdeed by able 
arguments ; his state of mind will have to be examined 
very closely to discover that he reasons from false 
premises. 

There is perhaps no class of persons so much to be 
pitied as those who act on impulse, especially when what 
they do has the aspect of premeditation. Such impulsive 
actions are particularly common amongst the uneducated. 
Irresistible impulse is, unfortunately, no mere fancy, 
invented for the special benefit of accused persons. It 
has a real existence. All children act on impulse ; edu- 
cation is supposed to give us deliberation and hesitancy. 
There are few persons in ordinary life, even amongst 
the sane, who are quite free from occasional impulses 
to commit acts which are inconsistent with strictly 
moral rectitude. The particular nature of the desire 
differs with the individual, and with the same person 
under different circumstances. In our ordinary state 
of health, an impulse to do something sudden or violent 
occurs to many. Some feel an impulse to throw them- 
selves down from a height or over the side of a vessel 
into the water. One person has a desire to scream in a 
crowded church or theatre, another to smash something 
valuable on the table. All these impulses are, by the 
healthy mind, resisted and controlled; but when the 
mind is not healthy, when by disease the controlling 

21 



322 THE VARIETIES OF INSANITY 

power of the higher centres is inhibited, then an insane 
impulse may be let loose in any direction — homicide, 
suicide, mere wanton smashing, or causeless violence. 

By an impulsive act is to be understood an act which 
is unpremeditated, which is undertaken on the spur of 
the moment, and without any, or with the minimum of, 
balancing of advantages and disadvantages to be obtained 
from the act. Impulsive acts are commonly the acts of 
those who have little power of self-restraint, and for 
this reason, as well as for their usually unprofitable char- 
acter, they are regarded with reprobation. An insane 
person will suddenly start up from a state of quiescence, 
and even of lethargy, and commit a violent or unprovoked 
assault or act of destructiveness without warning, and 
apparently without premeditation. 

Acts of extreme impulsiveness occur in neurasthenia 
(Chapter XVI) ; they are generally trifling, but cause 
great mental struggle and distress. When the act, such 
as pilfering, is committed, it is followed quickly by 
remorse. Hypomaniacs (Chapter XVIII) are amongst 
the insane most given to be the prey to their impulses, 
and as the disease progresses to acute mania, all 
power of inhibition is lost. Sufferers from epilepsy are 
especially liable to sudden outbursts (Chapter XXV). 
Epileptics, after a fit, frequently have a brief attack 
of furious mania before they recover consciousness. 
They are violent and destructive, being evidently 
excited by frightful hallucinations. After the attack 
has subsided, the individual returns to his normal 
condition, giving no indication of what he has gone 
through. In the less serious forms there may be no 
excitement, but the patient may act like a somnambulist, 
and do various things, normal, foolish, or criminal, of 
which he has no recollection on awakening. The person 
on whom the attack is made has, as a rule, no difficulty 
in restraining the patient, but a misfortune is almost 
sure to occur when the person attacked is asleep or is 
too feeble, as in the case of a child, to resist. Sometimes 
the dreamy state alone will take the place of a fit, and 
if the patient is suffering from minor epilepsy, which 
resemble simple fainting fits — i.e. without convulsions — 
it may be very difficult to convince a jury that a crime 



INSANITY AND THE LAW 323 

committed during this state is due to a disease and should 
exempt the patient from responsibility. 

To speak of insane impulses is not always correct. 
It is more often an " imperative idea/' or " imperative 
conception/ ' The idea has frequently been in their 
minds for a long time previously. The subject has been 
thinking and brooding over the matter until he has become 
controlled by the morbid idea. 

The forensic importance of these impulsive acts has 
not been so fully recognised as it ought to be. In cases 
of obsession the absence of motive for the crime, and the 
existence of a motive against it, are important factors 
in the determination of the degree of responsibility 
that is to attach to the accused. If a person applies to 
the police to be restrained from committing a crime to 
which he is impelled by an obsession, if he seeks medical 
advice to counteract the obsession, if he enters an asylum 
and submits to its restrictions from fear that he may be 
impelled to commit the crime, and if in spite of all these 
precautions, voluntarily taken, circumstances occur which 
render the crime possible, and he commits it, it seems 
clear that he ought not to be held fully responsible for it. 

From time to time crimes are committed for which 
no motive — or no motive that appears to the ordinary 
man adequate — can be assigned. Any one who reads 
the police reports must be struck by the number of 
apparently purposeless crimes that are committed. A 
husband murders his wife, with whom he has always 
appeared to be on affectionate terms ; a man assaults 
without provocation an unoffending stranger ; a woman 
murders the child to whom she has always been de- 
votedly attached; a wealthy woman turns shop-lifter; 
a wealthy man steals the spoons from the table at which 
he is a guest, and many other crimes are committed 
every year in which the motives appear to the onlooker 
utterly inadequate. It is not to be wondered at when we 
realise how large the proportion is of the " borderland," 
or semi-insane, intellects. In alcoholic mania (Chapter 
XXIII) an unmotived murder may occur and the patient 
have no recollection of his deed. 

To the sane criminal, the certainty of detection and 
punishment following on crime is a much more powerful 



324 THE VARIETIES OF INSANITY 

deterrent than the nature of the possible punishment that 
may ensue upon arrest. Whether criminal or not, every 
one is continually hoping to escape from the unpleasant 
consequences of misdeeds, however trivial those may be. 

The question of sanity has to be decided chiefly in 
cases of sexual crime, larceny, manslaughter, and murder. 

With reference to sexual crime, the chief offender is 
the man suffering from general paralysis of the insane 
(Chapter XXII). His sexual excitement, which at the 
commencement of his disease is often in excess, may 
result in rape, exposure of the person, and other acts of 
indecency. Such patients have lost the sense of pro- 
priety, and are apparently unconscious of doing wrong ; 
at least, they seem to take no precaution to prevent de- 
tection. In senile dementia (Chapter XXII), too, there 
is often erotic excitement, leading to assaults on children, 
paederasty, and other perverted manifestations. On the 
other hand, false accusations are often brought by 
hysterical young women (Chapter XVII) and elderly 
spinsters in the climacterium (Chapter XXIV), such as 
that liberties have been taken with them. 

Kleptomania (see also Chapter II) occurs in the mental 
disorder which sometimes accompanies pregnancy 
(Chapter XXIV). Theft may also occur in neurasthenia 
(Chapter XVI), but is usually followed by a frank con- 
fession. Weak-minded persons (Chapter XXVI) are 
prone to commit petty acts of larceny. The hypomaniac 
(Chapter XVIII) sometimes steals whatever he can lay 
his hands on, but the articles stolen are often thrown 
away as soon as they are in his possession, and he steals 
almost openly. General paralytics (Chapter XXII), in 
the early stage of the disease, not infrequently steal with- 
out reflection, though sometimes with ingenuity, as a 
rule any article that takes their fancy. They also 
commit frauds of every kind, generally neglecting 
ordinary precautions. In the later stages of general 
paralysis they again steal, but this time under the de- 
lusion that everything belongs to them. They then 
appropriate all sorts of articles, hoard and conceal them, 
and immediately afterwards lose all recollection of them. 

Theft may occur in persons who from childhood 
have been "morally weak-minded" and easily yielded 



INSANITY AND THE LAW 325 

to temptation (Chapter XXVI). Their insanity can be 
proved only by investigating their entire history, from 
infancy onwards, and by showing the co-existence of 
other defects of morality. 

Another important class of kleptomaniacs are those 
who are perfectly sane in every other respect, but have 
morbid impulses whenever there is any temptation to 
pilfer. Such impulsive stealing has certain points which 
it is of importance to know. The person may be rich 
and by no means ungenerous with his money, and may 
yet appropriate articles which are worthless in themselves 
and of no practical use to himself, the articles stolen 
being generally of the same kind — handkerchiefs, ties, 
watch-chains, scarf-pins, books ; moreover, the stolen 
goods are not parted with for personal gain, but are 
accumulated uselessly. The gratification is in the doing 
of the act, and when it is done, the thing stolen is not 
valued or desired. It is often given away, or put away 
and never inspected again. These are essential points 
which should be remembered in diagnosing a case of 
kleptomania from theft. 

As regards manslaughter and murder, assaults on a 
person, with or without intent to kill, are made in acute 
mania (Chapter XVIII). There need be no delusion what- 
ever ; the crime is simply the outcome of ungovernable 
passion. A person suffering from melancholia (Chapter 
XIX) may kill his wife and children, hearing the voice of 
God within him commanding him to do so. Often the 
delusion of the melancholic is that some terrible calamity 
is impending over himself and those who are near and 
dear to him, and to save them from the calamity he 
takes their lives and then his own. Persecutory halluci- 
nations and delusions may cause the acute alcoholic 
(Chapter XXIII) to turn upon his supposed enemies and 
attempt to kill them. Wife-beating, inhuman treatment 
of children, attacks upon associates as the effect of 
blind passion, are common to chronic alcoholism. As- 
saults may also occur as the result of delusions, as in 
paranoia (Chapter XXI), and may be unpremeditated 
or designed. The paranoiac kills a stranger, mistaking 
him for his long-sought enemy. The murder is done 
openly, and he justifies it. 



326 THE VARIETIES OF INSANITY 

Political paranoiacs are common. They are men 
with tainted brains who speculate on political affairs until 
they get fixed ideas that the State is mismanaged, that 
the people are wronged, or else they have imaginary 
grievances, or real but exaggerated, against certain 
officials. Paranoiacs dwell on these ideas so persistently, 
although in every other respect reasonable beings, that 
the brain, so to say, becomes soaked in them and the 
conduct becomes affected. They are particularly apt to 
make attacks on persons in high places, in order that 
the notoriety they thereby achieve may draw attention 
to their case. If a murder of some exalted personage 
is the result, popular indignation rises so high that 
even when the insanity is pronounced, feeble or no 
attempts are made to prove it. Many anarchists are 
men suffering from a form of paranoia, and, misguided 
by political obsessions, they think themselves perse- 
cuted and called on to act as martyrs and to kill some 
great person in the name of Liberty. 

In the case of a mother who has killed her infant, the 
possibility of puerperal mania (Chapter XXIV) should 
be remembered. 

A considerable number of murders are committed with 
such an excess of brutal and revolting violence as seems 
to establish a prima facie case of insanity in the murderer, 
and some of these are committed by persons known to 
be epileptic (Chapter XXV). In such cases the victim 
is not only killed, but mutilated or battered almost out 
of semblance of humanity. 

Here is one of the numerous examples one may read 
in the daily papers. It is copied from the newspapers 
of July 19th, 1908 : 

ROADSIDE MURDER 

DEATH SENTENCE FOR TERRIBLE CRIME 
JURY DISAGREE WITH DOCTORS' EVIDENCE 

Yesterday the Yorkshire roadside murder was the 
subject of investigation at Leeds Assizes, where James 
Jefferson, 21, labourer, of North Shields, was condemned 



INSANITY AND THE LAW 327 

to death for the murder of Mrs. Elizabeth Todd, 31, on 
the roadside at Otley Chevin, in May last. Mr. Bruce 
Williamson, for the Crown, said there arose the question 
as to prisoner's mental condition, and as to whether he 
was fit to plead. He proposed to submit evidence as 
to his mental condition. Medical evidence was then 
called. First, Dr. Edgerley, of Menston Asylum, gave 
evidence, and then Dr. Exley, of Armley Gaol. They 
both considered him unfit to plead, but the witnesses 
having been questioned by the judge at considerable 
length, the jury found that prisoner was fit to plead, and 
the trial proceeded. The murdered woman, wife of a 
shoemaker living near Otley, had been on a visit to her 
mother's house some little distance from her own home, 
and on her way back she was overtaken or was met by 
the prisoner. It is alleged that without any reason he 
assailed her with a knife. Ferocious and unexpected as 
was the onslaught, she made a valiant but unsuccess- 
ful fight for life. Repeated stabs killed her, and it was 
stated that accused was still wrestling with her dead 
body, endeavouring to cut off the head, when Mr. Helli- 
well, a provision dealer, driving along the road, was the 
horrified spectator of the terrible crime. Whipping up 
his horse, Mr. Helliwell dashed off at full speed for assis- 
tance. A quarter of a mile up the road he found some 
men, and drove back to the scene of the affair. By 
that time the man had disappeared, and so had the 
body, but after looking round the searchers espied over 
a wall the prisoner, who was hacking at the body, 
then headless and stripped of its clothing. Mr. Helli- 
well called out, but the prisoner made no reply, and 
continued to cut away at the victim's arm. Prisoner 
was seized, and he said, "I do not know what made 
me do it." At that time the woman's head was lying 
some distance away in the field. The crime created a 
great sensation by reason of the fiendish brutality and 
amazing callousness shown by the prisoner. Yesterday 
the chief interest in the case centred in the defence. 
Drs. Edgerley and Exley, recalled as witnesses for the 
defence, gave evidence. The former expressed the 
opinion that prisoner was mad, while the latter said 
he believed prisoner knew he was killing the woman, 



328 THE VARIETIES OF INSANITY 

but witness did not think he appreciated what he 
was doing. The evidence of Dr. Ellison, deputy medical 
officer of Armley Gaol, fully confirmed that of Dr. Exley. 
Mr. Lawrie, for the defence, ridiculed the idea of robbery, 
and, apart from that, urged that no sane man could 
have been guilty of the crime alleged against prisoner, 
who could not have had the smallest knowledge of the 
offence he had committed. The judge, in summing up, 
said there was no doubt prisoner had committed a murder 
of a ferocious and fearful character, and the only question 
was whether, when he committed the deed, he knew 
what he was doing. Prisoner, a feature of whose trial 
was that he had at first pleaded guilty, and then, at the 
instance of the judge, pleaded not guilty, was found 
by the jury to be guilty, and was sentenced to death. 
Prisoner, after jury's verdict, persisted that he was not 
in his right mind at the time the crime was committed. 

I may add that the Court of Appeal quashed the 
conviction. 

The act of homicidal insanity is different in its nature 
and moral causes from the crime of the murderer. There 
is either no motive or the act is committed under the 
influence of a motive which, to a sane mind, would be 
quite inadequate. 

The insane homicide often kills a number of victims 
at a time, slaughtering all within his reach. Murderers, 
on the other hand, seldom shed more blood than is 
necessary for the attainment of their object. 

The manner in which the murderer sets himself to the 
consummation of his crime as well as his subsequent 
conduct is very different from the proceedings of the 
madman. The former often has accomplices, he com- 
mences with premeditation, lays a plan beforehand, 
chooses time, place, and circumstances adapted to the 
perpetration of the deed, and generally has contrived 
some method of escape after the crime. He always 
studies concealment and personal safety, and when 
there is danger of detection, uses all possible cunning- 
ness to escape the punishment due to his crime. All 
these particulars are reversed in the proceedings of the 
madman. He has no accomplices, he never communi- 



INSANITY AND THE LAW 329 

cates his purpose to any human creature, he rushes on 
his victim, for the most part, as if driven by a sudden 
impulse, seizes whatever weapon chance throws in his 
way, and sometimes seems to be excited irresistibly to 
the attempt by the sight of implements fitted to his 
purpose. He lays no plan for escape, and seldom at- 
tempts it after perpetrating the act. Often he has been 
known to sit down quietly when he could easily escape, 
and wait till he is seized by the officers of justice. In 
many instances the insane homicide has avowed his act 
with perfect indifference, and without exhibiting any 
sign of regret or remorse, or apprehension of censure, or 
dread of punishment ; sometimes he has surrendered 
himself to officers of justice, and expressed a wish to 
suffer the penalty of the law. 

The victims of the madman are generally persons to 
whom he had been attached, often his relatives, his wife, 
and children ; sometimes they are persons whom he had 
never before seen, entire strangers against whom it is 
inconceivable that he could have any motive of malevo- 
lence. 

The great majority of inmates of Broadmoor Criminal 
Lunatic Asylum are under detention for grave crimes of 
personal violence — murder, manslaughter, or attempted 
murder — recent statistics showing that only eleven per 
cent, are under detention for other offences. In respect 
of crimes of violence against the person, epilepsy, alcoho- 
lism, and persecutory delusional insanity occupy positions 
of evil pre-eminence. 

In the course of thirty years there were at Broadmoor 
Asylum, amongst the total number of patients admitted, 
twelve per cent, who were described as epileptic. A 
tabulation of the crimes and offences of these epileptic 
patients showed that sixty-six were guilty of homicide, 
forty-one of attempts at homicide, twenty-eight of 
larceny, seven of arson, six of burglary, three of man- 
slaughter, and the rest of other offences. That epilepsy 
is not more frequent among criminal lunatics, as might 
be expected, may be explained by the fact that persons 
suffering from epilepsy are usually, when at large, kept 
under observation, and thereby prevented from com- 
mitting harmful acts. 



330 THE VARIETIES OF INSANITY 

Drink is doubtless a potent factor, either directly or 
indirectly, in the production of crime and insanity ; but 
it is very difficult, in the consideration of its influence, to 
estimate accurately how far it is the original, or, it may 
be, sole cause of the one or the other, or how far the 
drinking habit or drunkenness is more or less the effect 
of pre-existing mental weakness or mental instability. 
Each case has to be considered separately and on its 
own merits. No doubt, whatever, it frequently happens 
that an ordinary lunatic or weak-minded person is con- 
verted into a criminal by the toxic action of alcohol upon 
his brain. (See Chapters VIII and XXIII on Alcoholism.) 

The defence may wrongly assume drink as a cause of 
crime in a hypomaniac, whereas it is part of his insanity 
that he squanders money on drink and vice, and his con- 
dition is aggravated by alcohol and sexual excesses or 
perversity. 

As regards delusional insanity, the man who believes 
that he is the victim of a plot, by which he is continually 
being injured in mind, body, and estate, and who is 
haunted by the notion that the plotters are all around 
him, though he cannot identify them, may surely receive 
some consideration if he turns upon one of his neighbours 
and assaults him, even though he has no reason to, and 
may not associate his victim in any way with the plot. 
These patients often object to the defence of insanity 
in their behalf. They do not like to be called insane. 
They resent the imputation most vigorously, for it is a 
well-known characteristic of delusional patients to defend 
their delusions, and this they will do at the risk of their 
lives, even when on trial for murder. 

A delusion having the same power with a maniac as a 
rational belief with a sane person, it is not surprising 
that acts of violence, extending even to murder and 
suicide, are committed. As the law stands, an insane 
delusion is a defence to a criminal charge only when the 
imaginary facts would, if really existent, be a legal 
justification. If A kills B under the delusion that B 
has slandered him, he is guilty of murder. But if A 
kills B under the delusion that B is trying to kill him, 
he is not guilty of murder. 

Auditory hallucinations are often the precursor of 



INSANITY AND THE LAW 331 

insanity, and it should not be forgotten that the voices 
heard may incite to murder. I could quote several 
examples from my own practice. False accusations 
may be brought by insane persons owing to insulting 
voices they hear. Such a condition may lead to a care- 
fully planned action against particular individuals, or 
may result in a sudden violent attack on a chance passer- 
by who happened to look at the person or made some 
innocent remark. 

Voices may also be heard by apparently sane persons 
suffering from internal ear trouble, and this latter com- 
plaint, even without any auditory hallucinations, may 
lead to irresponsible actions by direct or reflex irritation 
of the brain. For illustrative cases see the author's book 
on Mental Symptoms of Brain Disease (Rebman, 1910). 

Injuries to the head sometimes cause a deterioration 
in brain energy and consequent weakening of the character 
with criminal dispositions. In others, injuries of the 
head give rise to morbid impulses of a criminal nature, 
which the person is conscious of, but cannot control. 
For cases descriptive of such a condition, see also the 
above-mentioned work. 

Technically, and in practice, the term " criminal 
lunatic ,! ' is not applied except to a person who has 
committed a crime, and who is for that reason under 
special detention as a lunatic ; and it matters not whether 
the priority of occurrence was with the insanity or with 
the criminal act — that is, whether the individual in ques- 
tion was insane when he committed the crime (King's 
Pleasure Lunatic) or was a criminal when he became 
insane (Secretary of State's Lunatic). Socially, of 
course, and in some senses psychologically (as in the 
matter of treatment), it is not unimportant to distinguish 
between an individual who, while insane, commits a 
crime, and a criminal — and more especially an habitual 
criminal — who becomes insane while undergoing im- 
prisonment — in short, between a criminal lunatic proper 
and an insane criminal. 

Besides the insane criminal and the criminal insane 
we have the far larger number of weak-minded criminals, 
who cannot be certified as insane, and for whom, until 
recently, there has been no other place than the ordinary 



332 THE VARIETIES OF INSANITY 

prison. If not insane, but weak-minded, the prisoner can 
now be sent to Parkhurst Convict Prison, where there is 
a special class of weak-minded convicts, who are kept 
there under observation and whose discipline is not of a 
penal character. If such weak-minded people, who are not 
wholly responsible, but who cannot be certified as insane, 
are sent to ordinary prisons, as they are in the majority 
of cases, for varying short terms, the punishment has no 
deterrent effect, and the probability is that they return 
again and again to prison for other offences at very short 
intervals. 

There is an immense number of mentally defective 
children for whom no provision is made, and for whom 
their own poor families are unable to care, hence they 
drift into crime for want of attention in early life. 
Feeble-minded children who commit lawless actions 
cannot be sent to an ordinary industrial school ; as soon 
as their mental condition is discovered, the school refuses 
to keep them. If they are not lunatics, and if they are 
not idiots, under the Idiots Act, they are uncared for 
by the State. The private and public institutions for 
idiots and imbeciles are so few in number — compared to 
the mass of weak-mindedness that exists in this country 
— that they really do not count. To remedy this state 
of affairs, there are two Bills before Parliament: the 
" Mental Defect Bill," based on the Royal Commission's 
Report and introduced by the Government, and the 
" Feeble-minded Control Bill," prepared conjointly by 
the National Association for the After-care of the Feeble- 
minded and the Eugenics Education Society. 

A large number of juvenile offenders, in whom the 
connection between mental defect and criminality may 
be observed in the earliest stages, come before the magis- 
trates. But unfortunately no advantage is at present 
taken of this opportunity of dealing with the evil at its 
first manifestation. At a little later stage these un- 
fortunates are sent to prison, or are " bound over," or 
are discharged. Unless certified as insane they cannot 
be detained. Even if treated as insane, which they can 
hardly be under the present law, on discharge to the 
workhouse, the Poor-Law medical officer and the 
magistrate may refuse certification and order of deten- 



INSANITY AND THE LAW 333 

tion. There is no institution intermediate between the 
prison and the lunatic asylum to which they may be 
admitted. 

The weak-mindedness of the accused may be proved 
- by arrested brain-growth, as in microcephalics, or there 
may be weak-mindedness due to hydrocephaly, besides 
other causes. (See Chapter XXVI.) 

To get at the true facts of responsibility, we must 
examine, therefore, not only the statistics of criminal 
lunatics, but also the statistics of mentally defective 
persons found in our prisons. I have before me the 
report of one prison doctor who, in his own institution, 
claims to have found ten and a half per cent, mentally 
defective criminals. In one gaol 600 mental defectives 
passed through in one year. Seventy cases had at 
least forty convictions each, while three had 102 and 
another ninety-four. At the same time, it must not be 
forgotten that there are many degrees of feeble-minded- 
ness, and that the simple occupations and surroundings of 
prison life make so little call upon the intelligence, that 
it is not always easy to estimate the degree or amount 
of defect. 

If the mental defect is of the intellectual variety, 
there is usually no difficulty in recognising it. But if 
the effect is a moral one, it is difficult for any one but 
the -expert to distinguish between iniquity and folly, 
wickedness and crime. For the offspring of poor parents, 
who suffer from moral weak-mindedness, there is nothing 
but the prison ; but even the offspring of wealthy parents 
often have to go to gaol, 

Many youths without any unusual incentive to crime, 
and with every possible inducement to virtue, are ob- 
served to abandon themselves wilfully to evil practices, 
and from their childhood to manifest a disposition 
presenting a strange compound of intellectual power and 
moral culpability. They suffer from an abnormal ex- 
citement of the passions and imperfect development of 
the higher moral sentiments. The parents may have 
consulted various experts in mental diseases, but no 
permanent improvement resulting, and further disgrace 
being brought upon the family, and all attempts to get 
the boy or girl certified as insane having failed, they have 



334 THE VARIETIES OF INSANITY 

to stand by while their child is sentenced as an incorrigible 
criminal, fortunately often under another name than 
that of the family. Again, I could cite various examples 
from my experience. 

One of the first signs of such moral weak-mindedness 
(Chapter XXVI) in early youth is an incapacity to tell 
the truth. These children lie to themselves and to 
others continually, until they are no longer capable of 
distinguishing clearly between that which has been 
experienced and that which has been invented. This 
habit, unless treated early, becomes rooted and remains 
through life. In adult years such persons cheat and 
make up things, either half consciously or quite uncon- 
sciously. They are instinctive liars, and are incapable 
of speaking the truth, even if they are put on their oath. 
Such a pathological liar confuses the products of his fancy 
with realities. False memories constantly disturb his 
reproductive faculty. Since he plunges with his whole 
attention into the deceptive creation of his fancy, in such 
a way that they become realities to him, he has an assured 
appearance, and he presents his humbugs and swindles 
so ingenuously and naturally, with such an innocent 
expression or with such unfeigned enthusiasm, that he 
succeeds again and again in convincing his fellow-men, 
where a conscious liar, who coolly and clearly measures 
his Words, in constant fear of contradicting himself or 
being trapped, meets with instinctive mistrust. In the 
consciousness of the common or normal liar, two trains 
of thought flow beside each other — the thought of the 
truth and the thought of the lie — and they trip each other 
up. In the brain of the pathological liar all is unified, 
and so he can carry through the most audacious swindles 
artistically and with inner conviction. Thus he drags 
a multitude of credulous souls with him to ruin. The 
public believe blindly in his alluring portrayals, his 
poetic effusions, his fairy tales, until at last some chance 
or the reflection of a thoughtful man brings the end 
with panic, and usually a sensation in the courts. Then, 
as though wakening from a dream, the pathological liar 
collapses, for the moment almost as astonished and dis- 
mayed as his victim — only to begin soon again, for he 
cannot help himself. 



INSANITY AND THE LAW 335 

In order to prove insanity of an alleged criminal, we 
ought to be able to prove either previous irrational acts 
or that the man was actually out of his mind at the time. 
Previous existence of head-injuries or of a history of epi- 
lepsy, as well as evidence of hereditary predispositions to 
insanity, will all assist in coming to a correct conclusion. 
There may be abnormalities in the shape of the head, 
anomalies of the pupils, motor or sensory disturbances, 
and loss of reflexes such as occur in the beginning of 
organic diseases of the brain and nervous system. There 
may be a history of haemorrhage or arterial disease 
affecting the brain, multiple sclerosis, or senile changes, 
etc. 

An expert in mental disease is almost sure in a genuine 
case to find other signs of insanity than are evident from 
the criminal act itself, and none but experts should be 
called upon to give evidence. 

We ought to mention here also, as being of interest 
to lawyers, the self -accusations of melancholies (Chapter 
XIX), which may lead to the arrest of the wrong person ; 
and the false accusation of others by paranoiacs (Chapter 
XXI), due to delusions. 

Foolish controversies, litigation, and criminal pro- 
ceedings may be started by persons suffering from 
hypomania (Chapter XVIII). Litigation is also often 
started in a particular form of paranoia (Chapter XXI). 
Unjust accusations are made and gross libels published 
in the maniacal stage of manic-depressive insanity 
(Chapter XX). This form is usually first apparent in 
its subjects after some disappointment in a law-suit, 
which apparently gives the starting-point for the building 
of delusions in the unstable mental organisation. The 
patients show their insanity in constant litigation. They 
are continually starting suits and demanding justice. 
They never recognise the real relation of things, and they 
build up extensive delusions as to the rights they are 
deprived of and the wrongs they have suffered. 

In conclusion, let me remark that one cause which has 
retarded the study of the mentally defective criminal 
is that amongst the general public there is a feeling of 
distrust that the tendency of the advancing study of 
the criminal is to ease him of responsibility and make 



336 THE VARIETIES OF INSANITY 

crime less repulsive by making excuses for it under the 
guise of psychopathic maladies, but no one has ever 
asserted that all criminals are mentally defective. There 
are many, no doubt, who are either weak-minded or 
of unsound mind, but they form a small percentage of 
the entire number of criminals, and we must remember 
that Society is bound to protect itself, whether the 
criminal be of sound or unsound mind. It must also 
not be forgotten that punishment sometimes stops even 
a lunatic from a criminal action. The conduct of most 
lunatics is in part sane and in part insane. While 
they may not properly be punished for the insane part 
of their conduct, they may properly be punished — 
though with mitigated severity — for wrong-doing, which 
belongs to the sane part of their conduct. Hence, some 
authorities hold that so long as the mind of the lunatic 
is clear enough to be capable of forming a true and 
intimate connection between the wrong-doing and the 
punishment which follows it, so long we are justified in 
inflicting upon him some punishment. The question of 
punishment is a matter for public opinion and the law 
to decide. But if the insane peison must be punished, 
let the punishment be frankly meted out to him as an 
insane and not as an ordinary criminal. 



INDEX 



Abdominal complaints, Mental 

disturbances in, 136 
Absent-mindedness, 68, 76,82,221 
Accusations, Wrongful, 254, 257, 

335 
Acquisitive impulse, Excess of, 

49, 52, 53, 182, 219, 324 
Acts, Impulsive, 45, 218, 293, 

309, 321, 323 
Acute mania, 45, 228 
./Esthetic sense, 82 
Affection for relatives and friends 

in insanity, 56, 57, 227, 228, 

229, 234, 248, 262, 265, 269, 

286, 293, 298, 301 
After-care of insane, 120, 193 
Age and insanity, 109, 246, 250, 

260, 264, 268, 285, 287, 290, 293 
Agitated melancholia, 45, 239 
Agoraphobia, 49, 216 
Alcoholic delirium, 275-277 

— insanity, 43, 44, 47, 49, 273- 
280, 325, 330 

Alcoholism as a cause of in- 
sanity, 43, 109, 123-130 

— Acute, 275-277 

— and crime, 52, 128, 275, 277, 

325, 330 
reformatory treatment, 128 

— Causes of, 125, 126 

— Chronic, 277-280 

— Heredity of, 99, 123 
Altruistic sentiment, Disorders 

of, 82, 182, 248, 278, 282, 306 
Amusements for the insane, 173 
Anarchists and paranoia, 326 
Anger, Manifestations of, 39, 

43-45, 134, 182, 214, 221, 224, 

226, 227, 229, 253, 257, 261, 

265, 270, 274, 279, 294 
Animal passions, Disorders of, 

41-54 
Anxiety and fear, Unreasonable, 

47> 4 8 > 49, 7°> 7 1 , *33, 136, 

22 337 



163, 214, 216, 231, 233, 237, 
246, 276, 282, 287, 290 
Apathy, 233, 240, 256, 265 
Appetite for food and its per- 
versions, 42-43, 64, 230, 237, 
252, 261, 268, 270, 283, 287 
Assassins, Political, 256, 326 
Asylum superintendents, 22 

— treatment of insane, 15-27, 186 
Asylums, Premature discharge 

from, 119 

— Private, 24 

— Voluntary boarders in, 16, 17 
Atavism, 100 
Attention, Defects of, 67, 182, 

214, 221, 239, 246, 264, 267, 
269, 293, 298, 302 
Auto-intoxication, 75, 116, 132, 

134 
Avarice and insanity, 50 

Backward children, 152, 207, 

297-310 
Bodily conditions as a cause of 

insanity, 131-140 

— symptoms, Importance of, 37 
Borderland insanity, 32, 35 
Brain fatigue, Mental symptoms 

of, 213-219 

— Functional disorders of, 36 

— injury and insanity, 138, 176- 
184 

— Mental functions of, 140, 143- 
151, 180, 212 

— Organic disorders of, 36, 38 

— tumours and insanity, 138, 
176, 183 

Broadmoor Criminal Lunatic 
Asylum, Statistics of, 329 

Catalepsy, 239 

Causes of insanity, 43, 91-140, 

153. 176-184, 202, 203, 204, 

260 



338 



INDEX 



Certification of insane, 16, 18, 
32, 108, 185, 191 

Change of life, Mental disorders 
of the, 43, 54, 61, 287-289, 324 

Character changes after head- 
injury, 138, 180 

in insanity, 36, 38, 41-90 

Chest complaints, Mental dis- 
turbances in, 136 

Childhood, Mental affections of, 
109, 223, 290-310 

Children, Backward, 152, 207, 
297-310 

— Faulty education of, 113, 153 

— Kleptomania in, 51, 324 

— Moral weak-mindedness in, 
305-310 

— Nervous, 153, 154 
Children of drunkards, 123 
insane parents, Treatment 

of, 104, 152, 192 

— Precocious, 153 
Choreic insanity, 291 
Circular insanity, 245-249 
Civilisation and insanity, 107- 

122, 264 
Classification of insanity, 212 

criminals, 311 

Claustrophobia, 49, 216 
Climacterium, Mental disorders 
^ of the, 43, 54, 61, 287-289, 324 
Cocaine intoxication, Mental 

symptoms of, 283-284 
Colony care of feeble-minded, 

207-210 
Concentration, Practice of, 157 
Conduct and insanity, 32, 37 
Confusion of thought, 69, 72, 133, 

228, 287 
Contagion of insanity, 122, 187 
Crime after head-injuries, 52, 

182, 331 

— and delusions, 325, 330 
drink, 52, 128, 275, 323, 325, 

330 
-insanity, 52, 182, 219, 249, 

254, 256, 281, 296, 307, 311-336 
weak-mindedness, 53, 307, 

324, 331-334 

— in acute mania, 229, 325 
alcoholism, 52, 128, 275, 

277. 325, 330 

delusional insanity, 325, 330 

dementia praecox, 266 

disorders of women, 53, 56, 

287, 324, 326 

epilepsy, 52, 296, 322, 326 

general paralysis, 53, 262, 324 



Crime in hypomania, 53, 321, 322, 

324 

— hysteria, 52, 324 

manic-depressive insanity, 

249 

— melancholia, 321, 325 

neurasthenia, 219, 322, 324 

-paranoia, 254, 256, 321, 

325, 326 

senile dementia, 53, 324 

Criminal lunacy in France, 314 
Criminals, Classification of sane, 

3ii 

— Insane, 52, 182, 219, 249, 
254, 256, 281, 296, 307, 311-336 

— Weak-minded, 53, 307, 324, 
331-334 

Culture and insanity, no 

Day-dreaming, 68, 76, 82, 221, 

224, 264 
Definition of insanity, 36, 40 
Degenerates, Segregation of, 206, 

207-210 

— Sterilisation of, 206 
Delirium, Alcoholic, 275-277 

— Hallucinatory-confusional, 73, 
132, 291 

— Inanition, 45, 64, 79, 132 

— of pneumonia, 134 
typhoid fever, 133 

— tremens, 275-277 
Delusions, 74-78 

— ■ and crime, 325, 330 

testamentary capacity, 272 

— in chronic alcoholism, 47, 279, 
280 

climacterium, 289 

dementia praecox, 77, 78, 

263-266 
general paralysis, 77, 78, 

260-263 

hypomania, 77, 78, 225-228 

lactational insanity, 287 

mania, 77, 78, 225-230 

manic-depressive insanity, 

248 
melancholia, 64, 77, 231- 

240, 325 

paranoia, 77, 78, 250-259,325 

senile dementia, 268-271 

— of exaltation, 37, 59, 77, 78, 
182, 225-230, 248, 254, 255, 261, 
263, 266 

jealousy, 60, 280, 284, 286, 

289 
poisoning, 43, 64, 237, 252, 

268, 287 



INDEX 



339 



Delusions of suspicion and persecu- 
tion, 45-47, 64, 77, 78, 134, 136, 
243, 250-259, 263, 270, 272, 277, 
279, 282, 283, 287 

— Systematised, 250-259 

— Treatment of, 164 
Dementia, 70, 266-272, 297 

— paralytica, Symptoms of, 43, 
44, 45, 47, 55, 57, 59, 67, 77, 
78, 81, 83, 243, 255, 280-283, 324 

— praecox, Symptoms of, 44, 57, 
69, 77> 79, 86, 263-266 

— Primary, 266-268 

— Secondary, 90, 230, 256, 267, 
280 

— senilis, 53, 55, 67, 109, 243, 
268-271, 324 

Depression, States of* 57, 77, 228, 

231-244, 246, 262, 268, 270 
Diabetes, Mental disturbances in, 

134 
Diagnosis of insanity, 31-40 
Disorders of intellect, 37, 46, 62- 
78, 82, 87, 144, 170, 179-182, 
213, 222, 225, 228, 234, 248, 
251, 254, 260, 264, 266, 267, 
268, 274, 278, 281, 283, 287, 

293, 305, 320 
memory, 66, 67, 180, 226, 

262, 264, 267, 269, 278, 288, 299 
perception, 62-66 

reason, 68 

the animal passions, 41-45 

-* egotistic feelings, 34, 58, 

257, 269, 3°i 
ethical sentiments, .82, 

83, 84, 182, 223, 248, 261, 

263, 268, 278, 282, 306 
religious sentiments, 85, 

182, 234, 254, 264, 265, 270, 293 
social feelings, 56, 57, 

227, 228, 229, 234, 248, 262, 

265, 269, 286, 293, 298, 301 
women, Mental symptoms 

in. 53. !37» 243, 285-289, 324, 

326 
Dream states in hysteria, 222, 224 
Drink and crime, 52, 128, 275, 

323. 325, 330 

— as a cause of insanity, 43, 109, 
123-130 

Drink-habit, Heredity of, 99, 123 

— in insane, 227, 245, 248 
Dual personality, 222, 246 

Ear-disease as a cause of insanity, 

182 
Eccentricity, 33, 89, 166, 256 



Education of children to prevent 
insanity, 152 

— versus heredity, 97, 98 
Educational over-pressure and .. 

insanity, 113, 153 
Egotistic feeling, Excess of, 34, 

58, 257, 269, 301 
Electrical treatment of insane, 173 
Emotional depression and in- 
sanity, 57, 77, 228, 231-244 
246, 262, 268, 270 

— exaltation and insanity, 37, 59, 
77, 78, 182, 225-230, 248, 254, 
255, 261, 263, 266 

Emotions in hysteria, 220 
Environment and insanity, 18, 

22, 36, 173 
Epilepsy and crime, 52, 296, 322, 

326 
Epileptic insanity, 44, .45, 64, 69, 

86, 293-298, 322, 326 
Erotic tendencies, 55, 255, 269, 

289 
Ethical sentiments and insanity, 

83, 182, 248, 278, 282, 306 
Eugenics, 199-206 
Exaltation, 37, 59, 77, 78, 182, 

225-230, 248, 254, 255, 261, 

263, 266 

— in dementia praecox, 266 

general paralysis, 59, 261 

head-injury, 182 

hypomania, 226 

-mania, 228 

manic-depressive insanity, 

248 

paranoia, 59, 254, 255, 263 

Exciting causes of insanity, 140 

Exophthalmic goitre, Mental dis- 
turbances in, 135 

Extravagance in insane, 51, 227, 
248, 261, 309 

Family care of insane, 196 

— influence on insane, 187 

— treatment in Belgium, 196 
Scotland, 196 

Fear and apprehension, Mani- 
festations of, 47, 48, 49, 70, 71, 
133, 136, 163, 214, 216, 231, 
233» 237, 246, 276, 282, 287, 
290 

— of public places, 49, 216 

enclosed spaces, 49, 216 

Febrile diseases and insanity, 139 
Feeble-minded children, 301-305 
Instruction of, 207 

— Colony care of, 207-210 

— Control Bill, 210, 332 



340 



INDEX 



Feeble-minded, Royal Commission 
on the care of, 26, 208, 
310 

— Segregation of, 207-210 

— Statistics of, 31, 310, 333 
Feelings, Excitement of, 37 

— Paralysis of, 234 

Fixed ideas, 48, 70-72, 157, 214, 

290, 326 
Flight of ideas, 68, 69, 225 
Food, Perversions of appetite for, 

42-43, 64, 230, 237, 252, 261, 

268, 270, 283, 287 
French procedure in pleas of 

insanity, 314 
Frontal lobes and intellect, 149, 181 
Furious mania, 45, 230, 263 

General paralysis. Symptoms of, 

43. 44. 45, 47, 54, 55> 57, 59, 
67, 77, 7 8 » 8i, 83, 243, 255, 
260-263, 324 

— practitioner and the treatment 
of insanity, 21 

Genius and insanity, 86, 259 
Gheel, 197 

Gluttony in insanity, 42, 261, 268 
Gout, Mental disturbances in, 134 
Graves' Disease, Mental symp- 
toms in, 135 
Grief, Excessive, 57, 231, 233, 268 

Haemorrhage and insanity, 138, 

176, 183 
Hallucinations, 62-65 

— in alcoholism, 64, 276, 279 
• cocainism, 284 

disorders of childhood, 290, 

292 

epileptic disorders, 64, 295 

hysteria, 64, 222 

inanition delirium, 64, 133 

— , — lactational insanity, 287 
— i — mania, 64, 229 

-melancholia, 64, 237 

opium poisoning, 282 

paranoia, 252 

puerperal mania, 64, 286 

— of hearing, 64, 65, 76, 252, 

295. 330 
sight, 64, 76, 237, 276, 279, 

282, 284, 287, 291, 292, 295 

smell, 64, 252, 277 

taste, 64, 237, 252, 277 

Hallucinatory confusional deli- 
rium, 73, 132, 291 
Handwriting of the insane, 80, 
225, 228, 298 



Head injuries and crime, 52, 182, 

33i 

— injury and insanity, 138, 176- 
184 

— Size of, 145, 150 
Hearing voices, 64, 6$ t 76, 252, 

295, 330 
Heart affections, Mental distur- 
bances in, 136 
Heat-stroke and insanity, 137 
Hereditary disposition to insanity, 

93-106, 202, 203, 204 
Hoarding instinct in insanity, 49, 

52, 53, 182, 219, 324 
Home treatment of insane, 195 
Homicidal insanity, 325, 328 
Hospital treatment of insane in 

Glasgow, 194 

Munich, 194 

Hygienic measures to prevent 

insanity, 160-175 
Hypnotism, Treatment of mental 

disorders by, 166 

— Extraordinary case of, 167 
Hypochondriacal melancholia, 238 
Hypochondriasis, 49, 80, 217, 221, 

238, 270 
Hypomania, Symptoms of, 15, 

43, 44, 47, 55, 57, 58, 69, 78, 

80, 225-228, 274, 321, 324, 335 
Hypomaniacs and crime, 53, 321, 

322, 324 

litigations, 335 

Hysteria, Symptoms of, 44, 49, 

52, 55, 64, 72, 82, 220-224, 324 

— and crime, 52, 324 

Ideas, Disorders of, 16, 66-78, 
133, 228, 267 

— Fixed, 48, 70-72, 157, 214, 
290, 326 

— Imperative, 70, 72, 321, 323 

— Occult, 86, 238, 252, 253, 254, 
265 

Idiocy, 67, 69, 183, 297-299 
Idleness and insanity, 159 
Illusions, 65, 76, 229, 237 
Imagination, Disorders of, 82, 87, 

222 
Imbecility, 45, 69, 81, 299-301 

— and dementia, their difference, 
70 

Immorality and drink, 128 
Imperative ideas, 70, 72, 321, 323 
Impulses, Suicidal, 44, 48, 218, 

235, 240, 243, 270, 287, 289 
Impulsive acts, 45, 218, 226, 293, 

309 



INDEX 



341 



Impulsive acts and crime, 321, 323 
Inanition delirium, 45, 64, 79, 132 
Incoherence, 68, 69, 133, 228, 267 
Increase in insanity, 107-122 
Indecision, 214, 218, 220, 233, 264, 

278, 284, 305 
Individual treatment of insane, 

22, 189 
Inebriety as a cause of insanity, 

43. 109, 123-130 
Infanticide, 56, 287, 326 
Influenza, Mental disturbances 

in, 134 
Insane, After care of, 120, 193 

— Amusements for the, 173 

— and their environment, 18, 
22, 36, 173 

— Asylum treatment of, 15-27, 
186 

— Certification of, 16, 18, 32, 108, 
185, 191 

— Character changes in, 38, 41-90 

— diathesis, 99, 101, 103, no 

— Family care of, 196 
influence on, 187 

— Handwriting of the, 80, 225, 
228, 298 

— Impulsive acts by, 45, 218, 293, 

309, 321, 323 

— Individual treatment of, 22, 
189 

— Nursing of, 21, 23, 174, 189 

— Occupation for, 171 

— Private treatment of, 17, 21, 
160-175, 195 

— Reception Houses for, 108, 191 

— Restriction of marriage of, 
199-206 

— Segregation of, 207-210 

— " Single " care of, 17, 160-175 

— Statistics of, 25, 31, 107, 112, 
119, 329 

— Sterilisation of, 206 

— Testamentary capacity of, 249, 
271-272, 305 

— their treatment a century ago, 

15 

— Travelling for, 165 

— Treatment in Scotland of, 27, < 
190, 196 

of children of, 152, 192 

— When is a person, 31-40 
Insanity and abnormal sexual 

habits, 55, 137, 262, 265, 279, 

289, 324 
absent-mindedness, 68, 76, 

82, 221, 224, 264 
affection for relatives and 



friends, 56, 57, 227, 228, 229, 
234, 248, 262, 265, 269, 286, 
293. 298, 301 
Insanity and age, 109, 246, 250, 

260, 264, 268, 285, 287, 290, 

293 
- -appetite for food, 42-43, 

64, 230, 237, 252, 261, 268, 270, 

283, 287 

avarice, 50 

choice of profession, 154 

civilisation, 107-122, 264 

— - — conduct, 32, 37 

crime, 52, 182, 219, 249, 

254, 256, 281, 296, 307, 311-336 
defective will-power, 214, 

218, 220, 233, 264, 278, 284, 305 
drink, 43, 99, 109, 123-130, 

227, 245, 248 
emotional depression, 57, 

77, 228, 231-244, 246, 262, 268, 
270 

exaltation, 37, 59, 77, 78, 

182, 225-230, 248, 254, 255, 

261, 263, 266 

ethical sentiments, 82, 83, 

84, 182, 223, 248, 261, 263, 268> 
278, 282, 306 

fear, 47, 48, 49, 70, 71, 133, 

136, 163, 214, 216, 231, 233, 
237, 246, 276, 282, 287, 290 

febrile diseases, 139 

functional disorders of the 

brain, 36 

genius, 86, 259 

hoarding instinct, 49, 52, 

53, 182, 219, 324 

idleness, 159 

influence of culture, no 

intellectual disorder, 37, 62- 

78, 144, 179-182, 213, 225, 
234, 248, 251, 254, 256, 260, 
264, 266, 268, 274, 278, 281, 
283, 287, 293, 305, 320 

■ — work, 114, 159 

irascibility, 39, 43-45, 134, 

182, 214, 221, 224, 226, 227, 

229, 253, 257, 261, 265, 270, 

274, 279, 294 
jealousy, 60, 280, 284, 286, 

289 
lack of attention, 67, 182, 

214, 221, 239, 246, 264, 267, 

269, 293, 298, 302 

love, 55, 248, 255, 269, 289 

of life, 42 

praise, 58 

— - — manslaughter, 325 



342 



INDEX 



Insanity and murder, 229, 254, 

256, 296, 325, 326, 328 
parental love, 55 

self-assurance, 58, 227, 248, 

261, 274, 303 
self-control, 32, 34, 35, 49, 

156, 203, 307, 308, 317, 321 
self-esteem, 35, 58-59, 226, 

236, 251, 255, 303 

self-introspection, 34, 60 

sex, 109, 232 

sexual excitement, 54, 55, 

137, 262, 265, 279, 289, 324 

shyness, 59 

social feelings, 56, 57, 227, 

228, 229, 234, 248, 262, 265, 

269, 286, 293, 298, 301 

society life, 113 

suicide, 42, 48, 218, 235, 

240-245, 270, 287, 289 
suspicion, 45-47, 64, 77, 

78, 134, 136, 252, 259, 263, 270, 

272, 279, 287 

temperament, no 

the Law, 16, 23, 32, 108, 

185, 311-336 

— medical practitioner, 21 

wrongful accusations, 254, 

257. 335 

— Borderline of, 32, 35 

— Case of surgical cure of, 177 

— caused by alcoholism, 43, 109, 
123-130 

bodily conditions, 131- 

140 
— brain-injury, 138, 176- 

184 
tumours, 138, 176, 183 

— — — ear-disease, 182 
educational over-pres- 
sure, 113, 153 

epilepsy, 293 

febrile diseases, 139 

heatstroke, 137 

hereditary - disposition, 

93-106, 202, 203, 204 

improper feeding, 139 

inebriety, 43, 109, 123- 

130 

mental and moral con- 
ditions, 107-122 

overstrain, 113, 115, 116, 

struggle for existence, 

in, 114 

sunstroke, 138 

surgical operations, 138 

syphilis, 137, 260, 269 



Insanity caused by toxins, 20, 75, 

116, 131-140. 176 
worry, 115, 118, 119, 

164, 284 

— Character changes in, 36, 38, 
41-90 

— Choreic, 291 

— Circular, 245-249 

— Classification of, 212 

— Contagion of, 122, 187 

— Danger of recurrent, 200 

— Defence on the ground of, 
314, 3i6, 335 

— Definition of, 36, 40 

— Diagnosis of, 31-40 

— Difference between medical and 
legal, 32, 316 

sanity and, 35, 70-74 

— Epileptic, 44, 45, 64, 69, 86, 
293-296 

— Exciting causes of, 140 

— First signs of, 31-40 

— following childbirth, 286 

— General signs of, 31 

— Hallucinations in, 62-65, 76, 
133, 222, 229, 237, 252, 276, 
277, 279, 282, 284, 286, 287, 
290, 291, 292, 295, 330 

— Homicidal, 229, 254, 256, 296, 
325, 326, 328 

— Illusions in, 65, 76, 229, 237 

— in women, 53, 137, 243, 285- 
289, 324, 326 

— Hereditary disposition to, 93- 
106, 202, 203, 204 

— Importance of bodily symp- 
toms in, 37 

— Increase in, 107-122 

- — Liability of various occupa- 
tions to, 115 

— Manic-depressive, 245-249, 335 

— Moral treatment of, 160-175 

— of the lactational period, 287 

— Periodic attacks of, 245-249 

— Predisposing causes of, 93- 
106, 140, 202, 203, 204 

— Prevention of, 141-210 

— Psycho-therapeutics of, 160™ 
175 

— Speech in, 39, 46, 47, 69, 79, 
225, 226, 228, 230, 234, 238, 
247, 262, 265, 274, 275, 283, 
286, 287, 298, 299, 300 

-—Statistics of, 25, 31, 107, 112, 

119. 3 IO » 329, 333 

— Surgical treatment of, 176-184 

— Toxic, 20, 131-140, 176 

— Treatment of, 15, 20, 141-210 






INDEX 



343 



Instruction of feeble-minded, 207 
Intellect and frontal lobes, 149, 

181 
the legal view of insanity, 

320 

— Disorders of, 37, 46, 62-78, 

82, 87, 144, 170, 179-182, 

213, 222, 225, 228, 234, 248, 
251, 254, 260, 264, 266, 267, 
268, 274, 278, 281, 283, 287, 

293. 305, 320 

— in alcoholic insanity, 274, 278 

cocaine intoxication, 283 

dementia, 69 

precox, 69, 264 

epileptic insanity, 69, 293 

feeble-mindedness, 302 

general paralysis, 260 

head-injury, 179-182 

idiocy, 69, 298 

imbecility, 69, 299 

mania, 225 

manic-depressive insanity, 

248 

melancholia, 234 

— moral weak-mindedness, 305 

neurasthenia, 213 

opium intoxication, 281 

paranoia, 251, 254, 256 

primary dementia, 266 

puerperal insanity, 287 

senile dementia, 268 

Intellectual overwork and in- 
sanity, 114, 159 
Intoxication and insanity, 20, 
75, 116, 131-140, 176 

— by alcohol, Symptoms of, 43, 
273-280 

cocaine, Symptoms of, 283- 

284 
opium, Symptoms of, 67, 

83, 281-283 

Irascibility in different forms of 
insanity, 39, 43-45, 134, 182, 

214, 221, 224, 226, 227, 229, 
253. 257, 261, 265, 270, 274, 
279, 294 

Irascible insanity after head in- 

injury, 180, 182 
Irresolution and insanity, 214, 

218, 220, 233, 264, 267, 278, 

284, 305 

Jealousy, 60, 280, 284, 286, 289 

— in alcoholism, 60, 280 

climacterium, 60, 289 

cocaine poisoning, 284 

-pregnancy, 286 



Kidney disease, Mental distur- 
bance in, 136 

Kleptomania, 51, 52, 53, 182, 
219, 324 

Kleptomaniacs distinguished from 
thieves, 52, 324 

Lactational insanity, 287 
Laughter, Silly, 265, 270, 274, 298 
Legal insanity, 16, 23, 32, 108, 

185, 311-336 
Legislation re feeble-minded, 210, 

332 
Liars, Pathological, 306, 334 
Litigations, Foolish, 256, 335 
Localisation of brain-function, 

146, 180-182 
London County Council's Re- 
ception House for Insane, 108, 
191 
Loquacity, 39, 69, 80, 225, 226, 

230, 238, 247, 274, 283, 286 
Love and insanity, 55, 248, 255, 

269, 289 

— of life, 42 

praise, Morbid manifesta- 
tion of, 58 

Lucid intervals, Testamentary 
capacity in, 272 

Lunacy, Stigma of, 18, 120 

— Commission, 16, 21, 25 

— Laws, 16, 23, 32, 108, 185, 
316-320 

Mania, 45, 53, 57, 64, 68, 69, 
77, 78, 80, 81, 225-230, 247, 
286, 294, 325 

— Alcoholic, 43, 44^ 47, 49, 273, 
280, 325, 330 

— Homicidal, 325, 328 

— in childhood, 291 
old age, 270 

— Periodic, 245 

— Questioning, 73 

— Violent, 45, 230, 263 
Manic-depressive insanity, 245- 

249, 335 
Manslaughter and insanity, 325 
Married life and insanity, 118 
Marriage restriction of insane, 

199-206 
Medico-legal cases, 318, 319, 326 
Melancholia, 45, 47, 49, 57» 59, 

60, 64, 68, 69, 72, 77, 79, 81, 

119, 182, 231-240, 243, 268, 

270, 321, 325, 335 

— Agitated form of, 45, 239 

— Chronic, 240 



344 



INDEX 



Melancholia,Hypochondriacal, 238 

— in childhood, 291, 294 

— Periodic, 245 

— Psycho-therapeutics of, 166 

— with delusions, 236 

stupor, 239 

Melancholic depression in old 

age, 270 
pregnancy, 286 

— state of manic-depressive in- 
sanity, 246 

Memory defects and testamentary 
capacity, 272 

— Disorders of, 66, 67, 180, 226, 
262, 264, 267, 269, 278, 288, 299 

Menstruation, Mental disturbance 

in, 285 
Mental affections of childhood, 

109, 223, 290-310 

— changes in climacterium, 43, 
54, 61; 287-289, 324 

pregnancy, 54, 64, 286, 

326 
< — Defect Bill, 210, 332 

— depression, States of, 55, 77, 
228, 231-244, 246, 262, 268, 270 

— discipline, 152-159 

■ — disorder, General signs of, 31 

— disorders due to intoxication, 
273-284 

toxines, 131-140 

of childhood, 109, 223, 290- 

310 
old age, 53, 55, 67, 109, 

243, 268-271, 324 
peculiar to women, 53, 137, 

273, 285-289, 324* 326 

— disturbances in abdominal com- 
plaints, 136 

chest complaints, 136 

— ■ diabetes, 134 

disordered menstruation, 

285 

exophthalmic goitre, 135 

gout, 134 

heart-affections, 136 

influenza, 134 

— kidney-disease, 136 

myxcedema, 135 

pneumonia, 134 

■ — typhoid fever, 133 

— enfeeblement, States of, 260- 
272 

— exaltation, States of, 37, 59, 
77, 78, 182, 225-230, 248, 254, 
255, 261, 263, 266 

— functions of the brain, 140, 
143-151, 180, 212 



Mental symptoms of alcoholic in- 
sanity, 43, 44, 47, 49, 273- 
280, 325, 330 

climacterium, 43* 54, 61, 

287-289, 324 

cocaine intoxication, 283- 

284 

dementia praecox, 44, 57, 

69, 77, 79, 86, 263-266 
epileptic insanity, 44, 45, 

52, 64, 69, 86, 293-296, 322, 326 

general paralysis, 43, 44, 

45, 47* 54. 55. 57, 59, 67, 77, 
81, 83, 243, 255, 260-263, 324 

hypomania, 15, 43, 44, 

47, 55, 57> 58, 69, 78, 80, 

225-228, 274, 321, 322, 324, 335 

hysteria, 44, 49, 52, 55, 

64, 72, 82, 220-224, 324 
mania, 45, 53, 57, 64, 

68, 69, 77, 78, 80, 81, 225- 
230, 247, 286, 294, 325 

manic-depressive insani- 
ty, 245-249, 325 

melancholia, 43, 47, 49, 

57. 59, 60, 64, 68, 69, 72, 77, 
79, 81, 119, 182, 231-240, 243, 
268, 270, 321, 325, 335 

neurasthenia, 43, 44, 49, 

70, 71, 72, 213-219, 243, 322, 

324 
opium intoxication, 67, 

83, 281-283 
■. paranoia, 47, 55, 57, 59, 

65, 72, 77, 78, 79, 81, 86, 250- 
259, 265, 321, 325, 326, 335 

primary dementia, 266- 

268 
puerperal insanity, 54, 

64, 286, 326 
secondary dementia, 90, 

230, 256, 267, 280 
senile insanity, 53, 55, 

67, 109, 243, 268-271, 324 
Microcephalic idiocy, Surgical 

treatment of, 182 
Mind and character, analysis of, 

40-90 
Miserly feeling, 50 
Moral nature, Disorders of, 82, 

83, 84, 223, 248, 261, 263, 268, 

278, 282, 306 

— treatment of insanity, 160-175 

— weak-mindedness, 53, 272, 305- 
310, 321, 324, 333, 334 

Morbid fears, 47, 48, 49, 70, 71, 
x 33, J 36, 163, 214, 216, 231, 
233. 237* 246, 276, 282, 287, 290 



INDEX 



345 



Murder and insanity, 229, 254, 
256, 296, 325, 326, 328 

Myxoedema, Mental disturbances 
in, 135 

Nervous children, 154 

— exhaustion, Mental symptoms 
of, 43, 44, 49, 7°. 7 1 , 72, 213- 
219, 243, 322, 324 

Nervousness, no 

Neurasthenia, Mental symptoms 

of, 43, 44, 49, 70, 71, 72, 213- 

219, 243, 322, 324 
Neuropathic disposition, 99, 101, 

103, no 
Night terrors, 292 
Nightmares, 293 
Nursing of the insane, 21, 23, 

174, 189 
Nymphomania, 54 

Observation Clinics for insane, 16, 

194 
Obsessions, 48, 71, 72, 214, 326 

— How to overcome, 157 

— in childhood, 290 

Occult ideas in insane, 86, 238, 

252, 253, 254, 265 
Occupation for the insane, 171 
Occupations, Liability to insanity 

of different, 109, 115 
Old age, Mental disorders of, 53, 

55. 67, 109, 243, 268-271, 324 
Prevention of insanity in, 

159 

Opium intoxication, Mental symp- 
toms of, 67, 83, 281-283 

Over-sensitiveness, 34, 38 

Paranoia, 47, 55, 57, 59, 65, 72, 
77. 78, 79, 81, 86, 250-259, 
265, 321, 325, 326, 335 

Paranoiacs and crime, 254, 256, 
321, 325, 326 

litigations, 335 

— False accusations by, 254, 257, 

335 

— Political, 256, 326 
Parental love, Morbid manifesta- 
tion of, 55 

Parkhurst Convict Prison and 

weak-minded criminals, 332 
Pathological liars, 306, 334 
Pauper patients, Difficulties in 

the treatment of, 17 
Perception, Disorders of, 62-66 
Periodic attacks of insanity, 245- 
249 



Periodic mania, 245 

— melancholia, 245 
Persecution, Delusions of, 45, 47, 

64, 77, 78, 134, 136, 243, 250- 
259, 263, 270, 272, 277, 279, 
282, 283, 287 

Personality, Alteration of, 77, 222 

Phobias, 70, 215-217 

— in childhood, 291 

Physical signs, Importance of, 37 

of alcoholic insanity, 275, 

276, 279 

cocaine intoxication, 283 

general paralysis, 262, 

263 

hysteria, 222 

lactational insanity, 287 

mania, 229 

■ — manic-depressive insan- 
ity, 248 

melancholia, 232, 234, 

239, 240 

neurasthenia, 214 

opium intoxication, 282, 

283 

paranoia, 252 

primary dementia, 268 

Pneumonia, Mental disturbances 
in, 134 

Poison in food, Delusion of, 43, 

64, 237, 252, 268, 287 
Political paranoiacs, 256, 326 
Prayer, Effect of, 85 
Precocious children, 153 
Predisposing causes of insanity, 

93-106, 140, 202, 203, 204 

Pregnancy, Mental disorders oc- 
curring in, 52, 53, 285, 324 

Premature mental weakness, 44, 
57. 69, 77, 79. 86, 263-266 

Preservation of the individual, 42 

species, 54 

Prevention of insanity, 141-210 

Primary dementia, 266-268 

Private asylums, 24 

— care, Treatment of insane in, 
185-198 

— treatment, Difficulties of, 17, 21 
of insane, 17, 21, 160-175, 

195 
Progressive insanity with syste- 
matised delusions, 47, 57, 59, 

65. 72, 77. 78, 79, 81, 86, 
250-259, 265, 321, 325, 326, 335 

Psychical blindness, 234 
Psychological analysis, 41 
Psychopathic disposition, 99, 10 1, 
103, no 



34^ 



INDEX 



Psycho-therapeutics of insanity, 

160-175 
Puerperal insanity, 56, 64, 286, 

326 

Questioning mania, 73 

Reason, Disorders of, 68 

Reception Houses for insane, 
108, 191 

Recurrent insanity, Dangers of, 
200 

Refusal of food, 43, 64, 237, 252, 
268, 287 

Religious sentiments, Disorders 
of, 85, 182, 234, 254, 264, 265, 
270, 293 

Remorse, Absence of, 254, 307, 
312 

Responsibility of insane, 314, 
316 , 

physicians in treating in- 
sane, 17 

Royal Commission on the Care 
and Control of the Feeble- 
minded, 26, 208, 310 

Sanity and insanity, Demarcation 

of, 33 

— Standard of, 36, 70, 74 

Satyriasis, 54 

Scotland, Treatment of insane 
in, 27, 190, 196 

Secondary dementia, 90, 230, 
256, 267, 280 

Segregation of insane and feeble- 
minded, 207-210 

Self -accusations, 83, 235-236, 247 

Self-assurance, 58, 227, 248, 261, 
274, 303 

Self-control, 32, 34, 35, 49, 156, 
203, 307, 308, 313, 317, 321 

Self-esteem, Diseased manifesta- 
tions of, 35, 58-59, 226, 236, 
251, 255, 303 

Self-introspection and insanity, 

34. 6o 
Self-preservation, 42, 241 
Senile dementia, Mental symp- 
toms of, 53, 55, 67, 109, 243, 
268-271, 324 
Sensitiveness, Extreme, 34, 38, 59, 

231, 251 
Sex and insanity, 109, 232 
Sexual propensity, Morbid mani- 
festations of, 54, 55, 137, 262, 
265, 279, 289, 324 
Shyness and insanity, 59 



Sight, Hallucinations of, 64, 76, 
237. 276, 279, 282, 284, 287, 
291, 292, 295 
Single care of patient, 17, 160-175 
Skull relation to brain, 151 
Smell, Hallucinations of, 64, 252, 

277 

Social affections, Morbid mani- 
festation of, 56, 57, 227, 228, 
229, 234, 248, 262, 265, 269, 
286, 293, 298, 301 

Speech in insanity, 39, 46, 47, 

69, 79, 225, 226, 230, 234, 238, 
247, 262, 265, 274, 275, 283, 
286, 287, 298, 299, 300 

Spiritual feeling, Disorders of, 85, 

182, 234, 254, 264, 265, 293 ' 
Statistics of Feeble-minded, 31, 

310, 333 
— ■ — Insane, 25, 31, 107, 112, 

119, 329 
Sterilisation of insane, 206 
Stigma of lunacy, 18, 120 
Stupor, 239, 247, 268, 287 
Suggestion, Treatment by, 160- 

175, 224 
Suicide, 42,48, 218, 235, 240-245, 

270, 287, 289 
Sunstroke and insanity, 138 
Surgical operations, Insanity 

after, 138 

— treatment of idiocy, 182 

insanity, 176-184 

Suspicion, 45-47, 64, 77, 78, 134, 

136, 250-259, 263, 270, 272, 
277, 279, 282, 283, 287 

— in alcoholism, 47, 279, 284 

cocaine intoxication, 282 

dementia prsecox, 77, 78, 

263-266 

^ lactational insanity, 287 

— ■ — melancholia, 47, 64 

paranoia, 47, 250, 252 

senile dementia, 270 

Symptoms, Importance of bodily, 

37 

— of hysteria, 44, 49, 52, 55, 64, 
72, 82, 220-224, 324 

neurasthenia, 43, 44, 49, 

70, 71, 72, 213, 219, 243, 
322, 324 

Syphilis and insanity, 137, 260, 
269 

Taciturnity, 69, 79, 234, 238, 

247, 265 
Taste, Hallucinations of, 64, 237, 

252, 277 



INDEX 



347 



Temper, Bad, 39, 43-45, 134. *54> 
182, 214, 221, 224, 226, 227, 
229, 253, 257, 261, 265, 270, 
274, 279, 294 

Temperament and insanity, no 

Temporary insanity, Treatment 
of, 20 

Testamentary capacity, 249, 271- 
272, 305 

Tetany, 239 

Thieving, 51, 52, 53, 182, 219, 

309, 324 
Thought, Rapidity of, 68, 69, 225 
Toxic insanity, 20, 75, 116, 131- 

140, 176 
Travelling for insane patients, 165 
Treatment in asylums, 15-27, 186 

private care, 185-198 

■ — mental and moral, 160-175 

— of children of insane, 104, 152, 
192 

— — delusions, 164 

insane a century ago, 1 5 

■ — in Scotland, 27, 190, 196 

insanity, 15, 20, 141-210 

pauper patients, Difficulties 

in, 17 

— Private, 17, 21, 160-175, 195 

— Surgical, 176-184 

Typhoid fever, Mental distur- 
bances in, 133 

' Undue influence in making wills, 

271, 305 
Untidiness, 233, 247, 268, 269, 
301 



Unworthiness, Feeling of, 59, 
235 

Veneration, Feeling of, 84 
Verbosity in insanity, 39, 69, 80, 

225, 226, 230, 238, 247, 274, 

283, 286 
Vivacity, Excessive, 226, 247, 261, 

274 
Visual hallucinations, 64, 76, 

237> 276, 279, 282, 284, 287, 

291, 292, 295 
Voices heard, 64, 65, 76, 252, 

295, 330 
Voluntary boarders in asylums, 
16, 17 

Weak-mindedness and crime, 53, 

307, 324, 331-334 
testamentary capacity, 272, 

3°5 

— Moral, 53, 272, 305-310, 321, 

324, 333, 334 
Will-making by insane, 249, 271- 

272, 305 
Will power, Defective, 214, 218, 

220, 233, 264, 267, 278, 284, 305 
Wit, Excessive, 226 
Women, Causes of insanity in, 137 

— Disposition to insanity of, 109, 
232 

— Mental disorders peculiar to, 
53, 137, 243, 285-289, 324, 326 

Wonder, Feeling of, 84 
Worry and insanity, 115, 118, 
119, 164, 284 



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RITA'S " NOVELS. 2/- NET EACH. 

Uniform Revised Edition in Cr. 8vo, cloth, coloured wrapper. 



The Countess Daphne. 

Corinna. 

Asenath of the Ford. 

Edelweiss. 



My Lord Conceit. 

The Man in Possession. 

Faustine. 

The Laird of Cockpen. 



" Rita" has a gift for portraying the emotions of the heart which few modern writers 
have equalled, and this new revised edition of her stories should meet with wide 
acceptance. 

2/- 
Sugar Round the Pill. E. W. Cole 

A cyclopedia of Fib, Fact and Fiction, containing some 1,500 
items of amusing and ingenious Falsehood and Fact, and 1,250 
items of Fun. In crown 8vo, cloth. 

44 



STANLEY PAUL'S 2/- (net) 
NOVELS 

Cr. 8vo, cloth, pictorial wrapper, 2s. net each. 

The Bungalow under the Lake (2nd edition). Charles £. 

Pearce 
Clive Liorimep's Marriage (2nd edition). E. Everett-Green 
Pretty Barbara (2nd edition). Anthony Dyllington 

Impertinent Reflections (5th edition). Cosmo Hamilton 

L»ying Ldps (2nd edition). William Le Queux 

The Riding Master (6th edition). Dolf Wyllarde 

In Fear of a Throne (2nd edition). 50 illustrations. R. Andom 
The Lion's Skin (2nd edition). Rafael Sabatini 

Young Nick and Old Nick (2nd edition). S. R. Crockett 
Love, the Thief (5th edition). Helen Mathers 

Tropical Tales (7th edition). Dolf Wyllarde 

The Cheerful Knave (4th edition). E. Keble Howard 

The Trickster (3rd edition). G. B. Burgin 

Love Besieged (3rd edition). Charles E. Pearce 

The Artistic Temperament (3rd edition). Jane Wardle 



1/6 NET 

The Diners-Out Vade Mecum. A pocket ''Who's Who "on 
the manners and customs of Society Functions, Toasts and 
Sentiments, Indoor Amusements, etc. Alfred H. Miles. In 
fcap. 8vo (6£ x 3|), cloth bound, round corners, is. 6d. net. 
Leather, 2s. net. 

Verses. Dolf Wyllarde 

With Photogravure Frontispiece. Paper, is. 6d. net. Cloth, 
2s. 6d. net. 



STANLEY PAUL'S 1/- (net) 
NOVELS 

Stiff pictorial board covers, Is. net ; cloth, 2s. net. 

22 The Garden of Life. 2nd Edition. . Kate Horn 

23 No. 5, John Street. 19th Edition. Richard Whiteing 

24 Dr. Phillips: A Maida-Vale Idyll. Frank Danby 
27 Tropical Tales. 7th Edition. Dolf Wyllarde 

1 The Widow— to say Nothing of the Man. Helen Rowland 

2 Thoroughbred. Francis Dodsworth 

45 



STANLEY PAUL'S 'CLEATl 
TYPE' SIXPENNY NOVELS 



46 
45 
44 

43 
42 

41 
40 
39 
38 
37 
36 
35 
34 
33 
32 
31 
30 
29 
aa 
27 

*6 

25 
24 

23 
22 
21 
20 

19 

18 

17 
16 

15 
14 
13 
12 
II 
10 

9 

8 

7 

6 

5 

4 
3 



NEW TITLES. 
Edelweiss 
Only an Actress 
The Apple of Eden 
Gay Lawless 

The Dream— and the Woman 
Love Besieged 
A Benedick in Arcady 
Justice of the King 
The Man in Possession 
A Will in a Well 

Ed-ward and I and Mrs. Honey bun. 
Priscilla of the Good Intent; 
Fatal Thirteen 
A Struggle for a Ring 
A Shadowed Life 
The Mystery of Colds Fell 
A Woman's Error 
Claribel's Love Story 
At the Eleventh Hour 
Love's Mask 
Tae i&'ooirag of Hose 
White Abbey 
Heart of his Heart 
■Ths Wonder of Love 
Co-Heiresses 

The Evolution of Katherina 
The Love of His Life 
A Charity Girl 
The House of Sunshine 
Dare and Do 
Beneath a Spell 
The Man She Married 
The Mistress of the Farm 
Little Lady Charles 
A Splendid Destiny 
Cornelius 
Traffic 
St. Elmo 
Indiscretions 
The Trickster 

The City of the Golden Gate 
Shoes of Gold 

Adventures of a Pretty Woman 
Troubled Waters 
The Human Boy Again 
Stolea Honey 



"Rita" 

"Rita* 

E. Temple Thurston 

Helen Mathers 

Tom Gallon 

Charles E. Pearck 

Halliwell Sutcliffe 

Hamilton Drummond 

"Rita" 

B. Everett-Green 

Kate Horn 

Halliwell Sutcliffe 

William Le Queux 

Charlotte Brame 

Charlotte Brame 

Charlotte Brame 

Charlotte Brame 

Charlotte Bramb 

Charlotte Brame 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Madame Albanesi 

Madame Albanesi 

E. Everett-Green 

E. Temple Thurston 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Effie Adelaide Rowlands 

Mrs. Henry de la Pasture 

E. Temple Thurston 

Augusta Evans Wilson 

Cosmo Hamilton 

G. B. Burgin 

E. Everett-Green 

Hamilton Drummond 

Florence Warden 

Headon Hill 

Eden Phillpotts 

Ada & Dudley James 



Massachusetts School 

for Feeble Minded*